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Grewal A, Thabet P, Dubinsky S, Purkayastha D, Wong K, Marko R, Hiremath S, Hutton B, Kanji S. Antimicrobial pharmacokinetics and dosing in critically ill adults receiving prolonged intermittent renal replacement therapy: A systematic review. Pharmacotherapy 2023; 43:1206-1220. [PMID: 37596844 DOI: 10.1002/phar.2861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 06/23/2023] [Accepted: 07/16/2023] [Indexed: 08/20/2023]
Abstract
Prolonged intermittent renal replacement therapy (PIRRT) is gaining popularity as a renal replacement modality in intensive care units, but there is a relative lack of guidance regarding antimicrobial clearance and dosing when compared with other modalities. The objectives of this systematic review were to: (1) identify and describe the pharmacokinetics (PK) of relevant antimicrobials used in critically ill adults receiving PIRRT, (2) evaluate the quality of evidence supporting these data, and (3) propose dosing recommendations based on the synthesis of these data. A search strategy for multiple databases was designed and executed to identify relevant published evidence describing the PK of antimicrobials used in critically ill adults receiving PIRRT. Quality assessment, evaluation of reporting, and relevant data extraction were conducted in duplicate. Synthesis of PK/pharmacodynamic (PD) outcomes, dosing recommendations from study authors, and physicochemical properties of included antibiotics were assessed by investigators in addition to the quality of evidence to develop dosing recommendations. Thirty-nine studies enrolling 452 patients met criteria for inclusion and provided PK and/or PD data for 20 antimicrobials in critically ill adults receiving PIRRT. Nineteen studies describe both PK and PD outcomes. Vancomycin (12 studies, 171 patients), meropenem (7 studies, 84 patients), and piperacillin/tazobactam (5 studies, 56 patients) were the most frequent antimicrobials encountered. The quality of evidence was deemed strong for 7/20 antimicrobials, and strong dosing recommendations were determined for 9/20 antimicrobials. This systematic review updates and addresses issues of quality in previous systematic reviews on this topic. Despite an overall low quality of evidence, strong recommendations were able to be made for almost half of the identified antimicrobials. Knowledge gaps persist for many antimicrobials, and higher quality studies (i.e., population PK studies with assessment of PD target attainment) are needed to address these gaps.
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Affiliation(s)
| | | | | | | | - Kristy Wong
- University of Waterloo, Waterloo, Ontario, Canada
| | - Ryan Marko
- The Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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2
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Passon SG, Schmidt AR, Wittmann M, Velten M, Baehner T. Evaluation of continuous ampicillin/sulbactam infusion in critically ill patients. Life Sci 2023; 320:121567. [PMID: 36907327 DOI: 10.1016/j.lfs.2023.121567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023]
Abstract
Continuous infusion (CI) of beta-lactam-antibiotics may improve pharmacodynamics in critically ill patients, but resulting concentrations have not been studied. Therapeutic drug monitoring is increasingly used to ensure antibiotic concentration. The aim of this study is to evaluate therapeutic ampicillin/sulbactam concentrations of a continuous infusion regimen. METHODS Medical records of all patients admitted to ICU between January 2019 and December 2020 were retrospectively reviewed. Each patient received a 2/1 g ampicillin/sulbactam loading dose, followed by a continuous infusion of 8/4 g per 24 h. Ampicillin serum concentrations were measured. Main outcomes were reaching of plasma concentrations breakpoint defined by minimum inhibitory concentration (MIC at 8 mg/l) and 4-fold MIC (MIC at 32 mg/l) during steady state of CI. RESULTS In 50 patients a total of 60 concentration measurements were performed. The first concentration was measured after a median of 29 h (IQR 21-61 h). Mean ampicillin concentration was 62.6 ± 39.1 mg/l. Furthermore, serum concentrations exceeded the defined MIC breakpoint in all measurements (100 %) and were above the 4-fold MIC in 43 analyses (71.1 %). However, patients suffering from acute kidney injury exhibited significant higher serum concentrations (81.1 ± 37.7 mg/l vs. 38.2 ± 24.8 mg/l; p < 0.001). Also, there was a negative correlation between ampicillin serum concentrations and GFR (r = -0.659; p < 0.001). CONCLUSION The described dosing regimen for ampicillin/sulbactam is safe with respect to the defined MIC breakpoints for ampicillin, and continuous subtherapeutic concentration is unlikely. However, with impaired renal function drug accumulation occurs, and with increased renal clearance, drug levels can be below the 4-fold MIC breakpoint.
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Affiliation(s)
- S G Passon
- Department of Anesthesiology and Intensive Care Medicine, St. Nikolaus Stiftshospital Andernach, Germany
| | - A R Schmidt
- Division of Pediatric Cardiac Anesthesia, Stanford University - School of Medicine, Palo Alto, CA, USA
| | - M Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany
| | - M Velten
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany.
| | - T Baehner
- Department of Anesthesiology and Intensive Care Medicine, St. Nikolaus Stiftshospital Andernach, Germany; Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Germany
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Rahbarimehr E, Chao HP, Churcher ZR, Slavkovic S, Kaiyum YA, Johnson PE, Dauphin-Ducharme P. Finding the Lost Dissociation Constant of Electrochemical Aptamer-Based Biosensors. Anal Chem 2023; 95:2229-2237. [PMID: 36638814 DOI: 10.1021/acs.analchem.2c03566] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Electrochemical aptamer-based (E-AB) biosensors afford real-time measurements of the concentrations of molecules directly in complex matrices and in the body, offering alternative strategies to develop innovative personalized medicine tools. While different electroanalytical techniques have been used to interrogate E-AB sensors (i.e., cyclic voltammetry, electrochemical impedance spectroscopy, and chronoamperometry) to resolve the change in electron transfer of the aptamer's covalently attached redox reporter, square-wave voltammetry remains a widely used technique due to its ability to maximize the redox reporter's faradic contribution to the measured current. Several E-AB sensors interrogated with this technique, however, show lower aptamer affinity (i.e., μM-mM) even in the face of employing aptamers that have high affinities (i.e., nM-μM) when characterized using solution techniques such as isothermal titration calorimetry (ITC) or fluorescence spectroscopy. Given past reports showing that E-AB sensor's response is dependent on square-wave interrogation parameters (i.e., frequency and amplitude), we hypothesized that the difference in dissociation constants measured with solution techniques stemmed from the electrochemical interrogation technique itself. In response, we decided to compare six dissociation constants of aptamers when characterized in solution with ITC and when interrogated on electrodes with electrochemical impedance spectroscopy, a technique able to, in contrast to square-wave voltammetry, deconvolute and quantify E-AB sensors' contributions to the measured current. In doing so, we found that we were able to measure dissociation constants that were either separated by 2-3-fold or within experimental errors. These results are in contrast with square-wave voltammetry-measured dissociation constants that are at the most separated by 2-3 orders of magnitude from ones measured by ITC. We thus envision that the versatility and time scales covered by electrochemical impedance spectroscopy offer the highest sensitivity to measure target binding in electrochemical biosensors relying on changes in electron-transfer rates.
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Affiliation(s)
- Erfan Rahbarimehr
- Département de chimie, Université de Sherbrooke, Sherbrooke, QuébecJ1K 2R1, Canada
| | - Hoi Pui Chao
- Department of Chemistry, York University, 4700 Keele Street, Toronto, OntarioM3J 1P3, Canada
| | - Zachary R Churcher
- Department of Chemistry, York University, 4700 Keele Street, Toronto, OntarioM3J 1P3, Canada
| | - Sladjana Slavkovic
- Department of Chemistry, York University, 4700 Keele Street, Toronto, OntarioM3J 1P3, Canada
| | - Yunus A Kaiyum
- Department of Chemistry, York University, 4700 Keele Street, Toronto, OntarioM3J 1P3, Canada
| | - Philip E Johnson
- Department of Chemistry, York University, 4700 Keele Street, Toronto, OntarioM3J 1P3, Canada
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Evaluation of the Correspondence between the Concentration of Antimicrobials Entering Sewage Treatment Plant Influent and the Predicted Concentration of Antimicrobials Using Annual Sales, Shipping, and Prescriptions Data. Antibiotics (Basel) 2022; 11:antibiotics11040472. [PMID: 35453223 PMCID: PMC9027251 DOI: 10.3390/antibiotics11040472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 02/05/2023] Open
Abstract
The accuracy and correspondence between the measured concentrations from the survey and predicted concentrations on the basis of the three types of statistical antimicrobial use in Japan was evaluated. A monitoring survey of ten representative antimicrobials: ampicillin (APL), cefdinir (CDN), cefpodoxime proxetil (CPXP), ciprofloxacin (CFX), clarithromycin (CTM), doxycycline (DCL), levofloxacin (LFX), minocycline (MCL), tetracycline (TCL), and vancomycin (VMC), in the influent of sewage treatment plant (STP) located in urban areas of Japan, was conducted. Then, the measured values were verified in comparison with the predicted values estimated from the shipping volumes, sales volumes, and prescription volumes based on the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB). The results indicate that the correspondence ratios between the predicted concentrations calculated on the basis of shipping and NDB volumes and the measured concentrations (predicted concentration/measured concentration) generally agreed for the detected concentration of antimicrobials in the STP influent. The correspondence ratio on the basis of shipping volume was, for CFX, 0.1; CTM, 2.9; LFX, 0.5; MCL, 1.9; and VMC, 1.7, and on the basis of NDB volume the measured concentration was CFX, 0.1; CTM, 3.7; DCL, 0.4; LFX, 0.7; MCL, 1.9; TCL, 0.6; and VMC, 1.6. To our knowledge, this is the first report to evaluate the accuracy of predicted concentrations based on sales, shipping, NDB statistics and measured concentrations for antimicrobials in the STP influent.
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The Role of Surface Enhanced Raman Scattering for Therapeutic Drug Monitoring of Antimicrobial Agents. CHEMOSENSORS 2022. [DOI: 10.3390/chemosensors10040128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The rapid quantification of antimicrobial agents is important for therapeutic drug monitoring (TDM), enabling personalized dosing schemes in critically ill patients. Highly sophisticated TDM technology is becoming available, but its implementation in hospitals is still limited. Among the various proposed techniques, surface-enhanced Raman scattering (SERS) stands out as one of the more interesting due to its extremely high sensitivity, rapidity, and fingerprinting capabilities. Here, we present a comprehensive review of various SERS-based novel approaches applied for direct and indirect detection and quantification of antibiotic, antifungal, and antituberculosis drugs in different matrices, particularly focusing on the challenges for successful exploitation of this technique in the development of assays for point-of-care tests.
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Shawwa K, Kompotiatis P, Sakhuja A, McCarthy P, Kashani KB. Prolonged exposure to continuous renal replacement therapy in patients with acute kidney injury. J Nephrol 2022; 35:585-595. [PMID: 34160782 PMCID: PMC8695624 DOI: 10.1007/s40620-021-01097-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/10/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Little is known about the process of deciding to discontinue continuous renal replacement therapy (CRRT) in patients with acute kidney injury (AKI) and the impact of CRRT duration on outcomes. METHODS We report the clinical parameters of prolonged CRRT exposure and predictors of doubling of serum creatinine or need for dialysis at 90 days after CRRT with propensity score matching, including covariates that were likely to influence patients in the prolonged CRRT group. RESULTS Among 104 survey responders, most use urine output (87%) to guide CRRT discontinuation, 24% use improvement in clinical or hemodynamic status. In the cohort study, of 854 included patients, 465 participated in the assessment of kidney recovery. Patients with prolonged CRRT had higher SOFA scores (11.9 vs. 11.2) and were more likely to be mechanically ventilated (99% vs. 84%) at CRRT initiation compared to patients without prolonged CRRT, p-value < 0.05. In multivariable logistic regression, daily urine output and cumulative fluid balance leading to CRRT discontinuation or day seven were independently associated with lower [OR 0.87 per 200 ml/day increase] and higher odds [OR 1.03 per 1-L increase] of requiring prolonged CRRT, respectively. After propensity score matching, prolonged exposure to CRRT was independently associated with increased risk of doubling serum creatinine or dialysis at 90 days, OR 3.1 (95% CI 1.23-8.3 p = 0.017). CONCLUSIONS Resolution of critical illness and signs of kidney recovery are important factors when considering CRRT discontinuation. Prolonged CRRT exposure may be associated with less chance of kidney recovery among survivors.
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Affiliation(s)
- Khaled Shawwa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA,Section of Nephrology, Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Panagiotis Kompotiatis
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Ankit Sakhuja
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Paul McCarthy
- Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA,Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, Heart and Vascular Institute, West Virginia University, Morgantown, WV, USA,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Matusik E, Boidin C, Friggeri A, Richard JC, Bitker L, Roberts JA, Goutelle S. Therapeutic Drug Monitoring of Antibiotic Drugs in Patients Receiving Continuous Renal Replacement Therapy or Intermittent Hemodialysis: A Critical Review. Ther Drug Monit 2022; 44:86-102. [PMID: 34772891 DOI: 10.1097/ftd.0000000000000941] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Antibiotics are frequently used in patients receiving intermittent or continuous renal replacement therapy (RRT). Continuous renal replacement may alter the pharmacokinetics (PK) and the ability to achieve PK/pharmacodynamic (PD) targets. Therapeutic drug monitoring (TDM) could help evaluate drug exposure and guide antibiotic dosage adjustment. The present review describes recent TDM data on antibiotic exposure and PK/PD target attainment (TA) in patients receiving intermittent or continuous RRT, proposing practical guidelines for performing TDM. METHODS Studies on antibiotic TDM performed in patients receiving intermittent or continuous RRT published between 2000 and 2020 were searched and assessed. The authors focused on studies that reported data on PK/PD TA. TDM recommendations were based on clinically relevant PK/PD relationships and previously published guidelines. RESULTS In total, 2383 reports were retrieved. After excluding nonrelevant publications, 139 articles were selected. Overall, 107 studies reported PK/PD TA for 24 agents. Data were available for various intermittent and continuous RRT techniques. The study design, TDM practice, and definition of PK/PD targets were inconsistent across studies. Drug exposure and TA rates were highly variable. TDM seems to be necessary to control drug exposure in patients receiving intermittent and continuous RRT techniques, especially for antibiotics with narrow therapeutic margins and in critically ill patients. Practical recommendations can provide insights on relevant PK/PD targets, sampling, and timing of TDM for various antibiotic classes. CONCLUSIONS Highly variable antibiotic exposure and TA have been reported in patients receiving intermittent or continuous RRT. TDM for aminoglycosides, beta-lactams, glycopeptides, linezolid, and colistin is recommended in patients receiving RRT and suggested for daptomycin, fluoroquinolones, and tigecycline in critically ill patients on RRT.
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Affiliation(s)
- Elodie Matusik
- Pôle Pharmacie & Pôle Urgences-Réanimation-Anesthésie, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Pharmacie, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon 1, EA 3738 CICLY - Centre pour l'Innovation en Cancérologie de Lyon, Oullins
| | - Arnaud Friggeri
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service d'Anesthésie, Médecine Intensive et Réanimation, Pierre-Bénite
- Univ Lyon, Université Claude Bernard Lyon, Faculté de Médecine Lyon Sud-Charles Mérieux, Oullins
- UMR CNRS 5308, Inserm U1111, Centre International de Recherche en Infectiologie, Laboratoire des Pathogènes Émergents
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Médecine Intensive Réanimation, Lyon
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR CNRS 5220, Inserm U1206, Villeurbanne, France
| | - Jason A Roberts
- Faculty of Medicine the University of Queensland, University of Queensland Centre for Clinical Research
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon ; and
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive Villeurbanne, France
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Rawlins MDM, Misko J, Roberts JA. Antimicrobial dosing in prolonged intermittent renal replacement therapy: a systematic review. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Matthew D. M. Rawlins
- Senior Pharmacist Antimicrobial Stewardship Pharmacy Department Fiona Stanley Hospital Murdoch Australia
| | - Jeanie Misko
- Medicines Information Senior Pharmacist Pharmacy Department Fiona Stanley Hospital Murdoch Australia
| | - Jason A. Roberts
- Faculty of Medicine University of Queensland Centre for Clinical Research The University of Queensland Brisbane Australia
- Departments of Pharmacy and Intensive Care Medicine Royal Brisbane and Women's Hospital Brisbane Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine Nîmes University Hospital University of Montpellier Nîmes France
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Suzuki T, Sugiyama E, Nozawa K, Tajima M, Takahashi K, Yoshii M, Suzuki H, Sato VH, Sato H. Effects of dosing frequency on the clinical efficacy of ampicillin/sulbactam in Japanese elderly patients with pneumonia: A single-center retrospective observational study. Pharmacol Res Perspect 2021; 9:e00746. [PMID: 33764686 PMCID: PMC7992287 DOI: 10.1002/prp2.746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 01/30/2021] [Accepted: 02/06/2021] [Indexed: 11/16/2022] Open
Abstract
This study sought to investigate whether dosing frequency (the number of doses per day) affects the antimicrobial efficacy and safety of ampicillin/sulbactam (ABPC/SBT) in Japanese elderly pneumonia patients treated with ABPC/SBT at 6 g/day. This was a retrospective observational study that included hospitalized elderly patients (aged ≥75 years, 10 ml/min ≤CLcr <50 ml/min) who received 3 g every 12 h (BID; n = 61) or 1.5 g every 6 h (QID; n = 45) for the treatment of pneumonia. The primary endpoint was clinical response, assessed by measuring body temperature, white blood cell count, and C-reactive protein levels. Pharmacokinetic and pharmacodynamic simulations were conducted in silico to rationalize the clinical findings. The clinical response rates (extremely effective and effective) in the BID and QID groups were 36.1% and 55.6%, respectively (p = .0459). QID tended to be more effective in patients with gram-negative rods detected (p = .0563). According to the simulated minimum plasma ABPC concentrations at steady state for BID and QID were 2.5 and 7.3 μg/ml, respectively (p < .0001). Based on the simulated time above minimum inhibitory concentration (MIC), pharmacological (not clinical) efficacy was predicted to be higher with QID. Both groups had similar safety profiles. The main adverse event in both groups was liver damage. The present retrospective survey demonstrated that ABPC/SBT treatment for elderly patients with pneumonia and renal dysfunction was more effective with QID than with BID. Therefore, the QID regimen is worthy of consideration to improve the clinical outcomes of ABPC/SBT therapy in the present patient population.
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Affiliation(s)
- Tomokazu Suzuki
- Division of Pharmacokinetics and PharmacodynamicsDepartment of PharmacologyToxicology and TherapeuticsSchool of PharmacyShowa UniversityTokyoJapan
- Department of PharmacyJapan Community Health Care Organization Tokyo Takanawa HospitalTokyoJapan
| | - Erika Sugiyama
- Division of Pharmacokinetics and PharmacodynamicsDepartment of PharmacologyToxicology and TherapeuticsSchool of PharmacyShowa UniversityTokyoJapan
| | - Kenji Nozawa
- Division of Pharmacokinetics and PharmacodynamicsDepartment of PharmacologyToxicology and TherapeuticsSchool of PharmacyShowa UniversityTokyoJapan
- Scientific Information DepartmentDevelopment DivisionFUJIFILM Toyama Chemical Co., LtdTokyoJapan
| | - Masataka Tajima
- Division of Pharmacokinetics and PharmacodynamicsDepartment of PharmacologyToxicology and TherapeuticsSchool of PharmacyShowa UniversityTokyoJapan
| | - Kyoka Takahashi
- Division of Pharmacokinetics and PharmacodynamicsDepartment of PharmacologyToxicology and TherapeuticsSchool of PharmacyShowa UniversityTokyoJapan
| | - Masayoshi Yoshii
- Department of PharmacyJapan Community Health Care Organization Tokyo Takanawa HospitalTokyoJapan
| | - Hidenori Suzuki
- Department of PharmacyJapan Community Health Care Organization Tokyo Takanawa HospitalTokyoJapan
| | - Vilasinee H. Sato
- Department of PharmacologyFaculty of PharmacyMahidol UniversityBangkokThailand
| | - Hitoshi Sato
- Division of Pharmacokinetics and PharmacodynamicsDepartment of PharmacologyToxicology and TherapeuticsSchool of PharmacyShowa UniversityTokyoJapan
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Karvouniaris M, Pontikis K, Nitsotolis T, Poulakou G. New perspectives in the antibiotic treatment of mechanically ventilated patients with infections from Gram-negatives. Expert Rev Anti Infect Ther 2020; 19:825-844. [PMID: 33270485 DOI: 10.1080/14787210.2021.1859369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Ventilator-associated pneumonia (VAP) is a common and potentially fatal complication of mechanical ventilation that is often caused by multidrug-resistant (MDR) Gram-negative bacteria (GNB). Despite the repurposing of older treatments and the novel antimicrobials, many resistance mechanisms cannot be confronted, and novel therapies are needed.Areas covered: We searched the literature for keywords regarding the treatment of GNB infections in mechanically ventilated patients. This narrative review presents new data on antibiotics and non-antibiotic approaches focusing on Phase 3 trials against clinically significant GNB that cause VAP.Expert opinion: Ceftazidime-avibactam, meropenem-vaborbactam, and imipenem-relebactam stand out as new options for infections by Klebsiella pneumoniae carbapenemase-producing bacteria, whereas ceftolozane-tazobactam adds therapeutic flexibility in Pseudomonas aeruginosa infections with multiple resistance mechanisms. Ceftazidime-avibactam and ceftolozane-tazobactam have relevant literature. Aztreonam-avibactam holds promise for the treatment of infections by metallo-β-lactamase (MBL)-producing organisms. Recently approved cefiderocol possesses an extended antibacterial spectrum, including KPC- and MBL-producers. However, recently published data have toned down optimism about treating VAP caused by carbapenem-resistant Acinetobacter baumannii. For the latter, eravacycline may provide additional hope, pending pertinent data. Non-antibiotic treatments currently being considered as adjunct therapeutic approaches are welcome. Nevertheless, they will hopefully substitute current antimicrobials in the future.
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Affiliation(s)
- Marios Karvouniaris
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Konstantinos Pontikis
- ICU First Department of Respiratory Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Thomas Nitsotolis
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
| | - Garyphallia Poulakou
- Third Department of Internal Medicine, School of Medicine, National and Kapodistrian University, Sotiria General Hospital, Athens, Greece
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Boss K, Wiegard-Szramek I, Dziobaka J, Kribben A, Dolff S. Intraperitoneal ampicillin treatment for peritoneal dialysis- related peritonitis with Listeria monocytogenes - a case report. BMC Nephrol 2020; 21:404. [PMID: 32948148 PMCID: PMC7501657 DOI: 10.1186/s12882-020-02068-1] [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: 07/03/2020] [Accepted: 09/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Peritoneal dialysis (PD)-related peritonitis is a rare but serious complication and is associated with increased morbidity and mortality rates. It is most commonly caused by Staphylococcus aureus or Staphylococcus epidermidis, but infection with Listeria monocytogenes may also occur. Recommendations for antibiotic treatment of a Listeria infection are currently based on a small number of case reports and suggest the administration of ampicillin. But unlike vancomycin or gentamicin, for ampicillin the route of application, the dosage, and the duration of treatment have not yet been established. We report a case in which PD-associated peritonitis due to Listeria infection was treated with ampicillin administered intravenously and intraperitoneally, separately and in combination. CASE PRESENTATION A 72-year-old man with chronic kidney disease stage 5 dialysis (CKDG5D) secondary to hypertension and diabetes was hospitalised in April 2020 because of PD-related peritonitis caused by a Listeria infection. In accordance with the results of resistance tests, the patient was treated with intravenous ampicillin at a dosage of 6 g twice daily. After initial treatment the leukocyte count in the PD effluent had decreased substantially, but it was permanently reduced only with the addition of intraperitoneal ampicillin (4 g daily). Efficient serum concentrations of ampicillin were determined for both routes of administration, intravenous and intraperitoneal. CONCLUSION This is the first case report demonstrating that PD-related peritonitis due to Listeria monocytogenes infection can be treated with intraperitoneal ampicillin and monitored by the determination of peripheral serum concentrations of ampicillin.
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Affiliation(s)
- Kristina Boss
- Department of Nephrology, University Hospital Essen, University-Duisburg Essen, 45147, Essen, Germany.
| | - Ina Wiegard-Szramek
- Department of Nephrology, University Hospital Essen, University-Duisburg Essen, 45147, Essen, Germany
| | - Jan Dziobaka
- Institute of Medical Microbiology, University Hospital Essen, University-Duisburg Essen, Essen, Germany
| | - Andreas Kribben
- Department of Nephrology, University Hospital Essen, University-Duisburg Essen, 45147, Essen, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University-Duisburg Essen, Essen, Germany
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12
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Brown P, Battistella M. Principles of Drug Dosing in Sustained Low Efficiency Dialysis (SLED) and Review of Antimicrobial Dosing Literature. PHARMACY 2020; 8:pharmacy8010033. [PMID: 32182835 PMCID: PMC7151685 DOI: 10.3390/pharmacy8010033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/17/2020] [Accepted: 03/06/2020] [Indexed: 12/04/2022] Open
Abstract
The use of sustained low-efficiency dialysis (SLED) as a renal replacement modality has increased in critically ill patients with both acute kidney injury (AKI) and hemodynamic instability. Unfortunately, there is a paucity of data regarding the appropriate dosing of medications for patients undergoing SLED. Dose adjustment in SLED often requires interpretation of pharmacodynamics and pharmacokinetic factors and extrapolation based on dosing recommendations from other modes of renal replacement therapy (RRT). This review summarizes published trials of antimicrobial dose adjustment in SLED and discusses pharmacokinetic considerations specific to medication dosing in SLED. Preliminary recommendation is provided on selection of appropriate dosing for medications where published literature is unavailable.
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Affiliation(s)
- Paula Brown
- Pharmacy Department, University Health Network, Toronto, ON M4G 2C4, Canada;
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
| | - Marisa Battistella
- Pharmacy Department, University Health Network, Toronto, ON M4G 2C4, Canada;
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada
- Correspondence:
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13
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Sethi SK, Mittal A, Nair N, Bagga A, Iyenger A, Ali U, Sinha R, Agarwal I, de Sousa Tavares M, Abeyagunawardena A, Hanif M, Shreshtha D, Moorani K, Asim S, Kher V, Alhasan K, Mourani C, Al Riyami M, Bunchman TE, McCulloch M, Raina R. Pediatric Continuous Renal Replacement Therapy (PCRRT) expert committee recommendation on prescribing prolonged intermittent renal replacement therapy (PIRRT) in critically ill children. Hemodial Int 2020; 24:237-251. [PMID: 32072767 DOI: 10.1111/hdi.12821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/06/2020] [Accepted: 01/12/2020] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Recently, prolonged intermittent renal replacement therapies (PIRRT) have emerged as cost-effective alternatives to conventional CRRT and their use in the pediatric population has started to become more prominent. However, there is a lack of consensus guidelines on the use of PIRRT in pediatric patients in an intensive care setting. METHODS A literature search was performed on PubMed/Medline, Embase, and Google Scholar in conjunction with medical librarians from both India and the Cleveland Clinic hospital system to find relevant articles. The Pediatric Continuous Renal Replacement Therapy workgroup analyzed all articles for relevancy, proposed recommendations, and graded each recommendation for their strength of evidence. RESULTS Of the 60 studies eligible for review, the workgroup considered data from 37 studies to formulate guidelines for the use of PIRRT in children. The guidelines focused on the definition, indications, machines, and prescription of PIRRT. CONCLUSION Although the literature on the use of PIRRT in children is limited, the current studies give credence to their benefits and these expert recommendations are a valuable first step in the continued study of PIRRT in the pediatric population.
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Affiliation(s)
| | | | - Nikhil Nair
- Department of Chemistry Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Arpana Iyenger
- Pediatric Nephrology, St John's Medical College, Bangalore, India
| | - Uma Ali
- Pediatric Nephrology, Lilavati Hospital and Research Center and SRCC Children's Hospital, Mumbai, India
| | - Rajiv Sinha
- Pediatric Nephrology, Medanta, The Medicity, Gurgaon, India.,Pediatric Nephrology, National Institute of Child Health, Kolkata, India
| | | | | | | | - Mohammed Hanif
- Pediatric Nephrology, Bangladesh Institute of Child health, Dhaka, Bangladesh
| | | | - Khemchand Moorani
- Pediatric Nephrology, National Institute of Child Health, Karachi, Pakistan
| | - Sadaf Asim
- Pediatric Nephrology, National Institute of Child Health, Karachi, Pakistan
| | - Vijay Kher
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, India
| | - Khalid Alhasan
- Pediatric Nephrology, King Saud University College of Medicine, Riyadh, Saudi Arabia
| | - Chebl Mourani
- Pediatrics, Hôtel-Dieu de France Hospital (HDF), Beirut, Lebanon
| | | | - Timothy E Bunchman
- Pediatric Nephrology & Transplantation, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mignon McCulloch
- Pediatric Nephrology, University of Cape Town - Cape Town, Western Cape, South Africa
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Akron, Ohio
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Boidin C, Moshiri P, Dahyot-Fizelier C, Goutelle S, Lefeuvre S. Pharmacokinetic variability of beta-lactams in critically ill patients: A narrative review. Anaesth Crit Care Pain Med 2019; 39:87-109. [PMID: 31513935 DOI: 10.1016/j.accpm.2019.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 07/05/2019] [Accepted: 07/31/2019] [Indexed: 11/25/2022]
Abstract
The use of antibacterial drugs is very common in critically ill patients and beta-lactam agents are widely used in this context. Critically ill patients show several characteristics (e.g., sepsis, renal impairment or conversely augmented renal clearance, renal replacement therapy) that may alter beta-lactam pharmacokinetics (PK) in comparison with non-critically ill patients. This narrative literature review aims to identify recent studies quantifying the variability of beta-lactams volume of distribution and clearance and to determine its main determinants. Seventy studies published between 2000 and 2018 were retained. Data on volume of distribution and clearance variability were reported for 5 penicillins, 3 beta-lactamase inhibitors, 6 cephalosporins and 4 carbapenems. Data confirm specific changes in PK parameters and important variability of beta-lactam PK in critically ill patients. Renal function, body weight and use of renal replacement therapy are the principal factors influencing PK parameters described in this population. Few studies have directly compared beta-lactam PK in critically ill versus non-critically ill patients. Conclusions are also limited by small study size and sparse PK data in several studies. These results suggest approaches to assess this PK variability in clinical practice. Beta-lactam therapeutic drug monitoring seems to be the best way to deal with this issue.
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Affiliation(s)
- Clément Boidin
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France.
| | - Parastou Moshiri
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
| | - Claire Dahyot-Fizelier
- CHU de Poitiers, Service d'Anesthésie-Réanimation, 2, rue de la Milétrie, 86021 Poitiers, France; Université de Poitiers, UMR 1070, 6, rue de la Milétrie, 86073 Poitiers, France.
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital Pierre Garraud, Service pharmacie, 136, rue du Commandant Charcot, 69005 Lyon, France; Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Bât. Grégor Mendel, 43, boulevard du 11 novembre 1918, 69622 Villeurbanne Cedex, France; Univ Lyon, Université Claude Bernard Lyon 1, ISPB - Faculté de Pharmacie de Lyon, 8, avenue Rockefeller, 69008 Lyon, France.
| | - Sandrine Lefeuvre
- CHR d'Orléans, Laboratoire de Biochimie, 14, avenue de l'hôpital, 45100 Orléans, France.
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Hoff BM, Maker JH, Dager WE, Heintz BH. Antibiotic Dosing for Critically Ill Adult Patients Receiving Intermittent Hemodialysis, Prolonged Intermittent Renal Replacement Therapy, and Continuous Renal Replacement Therapy: An Update. Ann Pharmacother 2019; 54:43-55. [PMID: 31342772 DOI: 10.1177/1060028019865873] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective: To summarize current antibiotic dosing recommendations in critically ill patients receiving intermittent hemodialysis (IHD), prolonged intermittent renal replacement therapy (PIRRT), and continuous renal replacement therapy (CRRT), including considerations for individualizing therapy. Data Sources: A literature search of PubMed from January 2008 to May 2019 was performed to identify English-language literature in which dosing recommendations were proposed for antibiotics commonly used in critically ill patients receiving IHD, PIRRT, or CRRT. Study Selection and Data Extraction: All pertinent reviews, selected studies, and references were evaluated to ensure appropriateness for inclusion. Data Synthesis: Updated empirical dosing considerations are proposed for antibiotics in critically ill patients receiving IHD, PIRRT, and CRRT with recommendations for individualizing therapy. Relevance to Patient Care and Clinical Practice: This review defines principles for assessing renal function, identifies RRT system properties affecting drug clearance and drug properties affecting clearance during RRT, outlines pharmacokinetic and pharmacodynamic dosing considerations, reviews pertinent updates in the literature, develops updated empirical dosing recommendations, and highlights important factors for individualizing therapy in critically ill patients. Conclusions: Appropriate antimicrobial selection and dosing are vital to improve clinical outcomes. Dosing recommendations should be applied cautiously with efforts to consider local epidemiology and resistance patterns, antibiotic dosing and infusion strategies, renal replacement modalities, patient-specific considerations, severity of illness, residual renal function, comorbidities, and patient response to therapy. Recommendations provided herein are intended to serve as a guide in developing and revising therapy plans individualized to meet a patient's needs.
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Affiliation(s)
- Brian M Hoff
- Northwestern Memorial Hospital, Chicago, IL, USA
| | - Jenana H Maker
- University of the Pacific Thomas J. Long School of Pharmacy and Health Sciences, Stockton, CA, USA.,University of California Davis Medical Center, Sacramento, CA, USA
| | - William E Dager
- University of California Davis Medical Center, Sacramento, CA, USA
| | - Brett H Heintz
- University of Iowa College of Pharmacy, Iowa City, IA, USA.,Iowa City Veterans Affairs (VA) Health Care System, Iowa City, IA, USA
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Veiga RP, Paiva JA. Pharmacokinetics-pharmacodynamics issues relevant for the clinical use of beta-lactam antibiotics in critically ill patients. Crit Care 2018; 22:233. [PMID: 30244674 PMCID: PMC6151903 DOI: 10.1186/s13054-018-2155-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/08/2018] [Indexed: 12/15/2022] Open
Abstract
Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients and beta-lactams are the most common antibiotic class used. Critically ill patient's pathophysiological factors lead to altered pharmacokinetics and pharmacodynamics of beta-lactams.A comprehensive bibliographic search in PubMed database of all English language articles published from January 2000 to December 2017 was performed, allowing the selection of articles addressing the pharmacokinetics or pharmacodynamics of beta-lactam antibiotics in critically ill patients.In critically ill patients, several factors may increase volume of distribution and enhance renal clearance, inducing high intra- and inter-patient variability in beta-lactam concentration and promoting the risk of antibiotic underdosing. The duration of infusion of beta-lactams has been shown to influence the fT > minimal inhibitory concentration and an improved beta-lactam pharmacodynamics profile may be obtained by longer exposure with more frequent dosing, extended infusions, or continuous infusions.The use of extracorporeal support techniques in the critically ill may further contribute to this problem and we recommend not reducing standard antibiotic dosage since no drug accumulation was found in the available literature and to maintain continuous or prolonged infusion, especially for the treatment of infections caused by multidrug-resistant bacteria.Prediction of outcome based on concentrations in plasma results in overestimation of antimicrobial activity at the site of infection, namely in cerebrospinal fluid and the lung. Therefore, although no studies have assessed clinical outcome, we recommend using higher than standard dosing, preferably with continuous or prolonged infusions, especially when treating less susceptible bacterial strains at these sites, as the pharmacodynamics profile may improve with no apparent increase in toxicity.A therapeutic drug monitoring-guided approach could be particularly useful in critically ill patients in whom achieving target concentrations is more difficult, such as obese patients, immunocompromised patients, those infected by highly resistant bacterial strains, patients with augmented renal clearance, and those undergoing extracorporeal support techniques.
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Affiliation(s)
- Rui Pedro Veiga
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
| | - José-Artur Paiva
- Centro Hospitalar São João, EPE – Intensive Care Department, Porto, Portugal
- Faculty of Medicine – University of Porto, Porto, Portugal
- Grupo Infeção e Sepsis, Porto, Portugal
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Sethi SK, Krishnappa V, Nangethu N, Nemer P, Frazee LA, Raina R. Antibiotic Dosing in Sustained Low-Efficiency Dialysis in Critically Ill Patients. Can J Kidney Health Dis 2018; 5:2054358118792229. [PMID: 30116545 PMCID: PMC6088477 DOI: 10.1177/2054358118792229] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/14/2018] [Indexed: 11/16/2022] Open
Abstract
Purpose of review Sustained low-efficiency dialysis (SLED) is increasingly used as a renal replacement modality in critically ill patients with acute kidney injury (AKI) and hemodynamic instability. There is, therefore, a greater need for the understanding of the antibiotic dosage and pharmacokinetics in these patients, to provide them with optimal therapy. Sources of information PubMed/Medline, Embase, and Google Scholar. Methods PubMed/Medline, Embase, and Google Scholar databases were searched using a combination of key words: dialysis, end stage renal disease, renal failure, sustained low efficiency dialysis, extended daily dialysis, prolonged intermittent renal replacement therapy (PIRRT), and antibiotic dosing. Studies that investigated antibiotic dosing and pharmacokinetics during SLED/extended daily dialysis/PIRRT were selected for this review. Key findings Eleven studies met inclusion criteria and selected for data extraction. The data with regard to dialysis specifications, type of antibiotic including dosages, drug clearances, and dosage recommendations are summarized in Table 1. It is a challenge to find therapeutic doses for antibiotics during SLED therapy because, in general, only aminoglycosides and vancomycin can be assayed in clinical laboratories. Limitations Although current studies on antibiotic dosing in SLED are limited due to diverse and undersized patient populations, antibiotic dosage adjustments for patients receiving SLED discussed here will serve as a valuable guide. Future large-scale research should focus on establishing guidelines for antibiotic dosage in SLED. Implications Pharmacokinetic principles should be taken into consideration for the appropriate dosing of drugs during SLED, yet it is vital to monitor response to drug to make sure therapeutic goals are achieved. Antibiotic dosing and timing relative to the initiation of SLED may be important to maximize either the time above the minimum inhibitory concentration (MIC) (time-dependent) or the peak to MIC ratio (concentration-dependent), balancing efficacy and toxicity concerns. Critical care physicians should liaise with nephrologists to make decisions regarding appropriate antibiotic dosing in patients undergoing SLED.
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Affiliation(s)
- Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta the Medicity, Gurgaon, Haryana, India
| | - Vinod Krishnappa
- Cleveland Clinic Akron General/Akron Nephrology Associates, OH, USA.,Northeast Ohio Medical University, Rootstown, OH, USA
| | - Nisha Nangethu
- Cleveland Clinic Akron General/Akron Nephrology Associates, OH, USA
| | - Paul Nemer
- Cleveland Clinic Akron General/Akron Nephrology Associates, OH, USA
| | | | - Rupesh Raina
- Cleveland Clinic Akron General/Akron Nephrology Associates, OH, USA.,Department of Nephrology, Cleveland Clinic Akron General and Akron Children's Hospital, OH, USA
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18
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Sinha R, Sethi SK, Bunchman T, Lobo V, Raina R. Prolonged intermittent renal replacement therapy in children. Pediatr Nephrol 2018; 33:1283-1296. [PMID: 28721515 DOI: 10.1007/s00467-017-3732-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/22/2017] [Accepted: 05/31/2017] [Indexed: 12/15/2022]
Abstract
Wide ranges of age and weight in pediatric patients makes renal replacement therapy (RRT) in acute kidney injury (AKI) challenging, particularly in the pediatric intensive care unit (PICU), wherein children are often hemodynamically unstable. Standard hemodialysis (HD) is difficult in this group of children and continuous veno-venous hemofiltration/dialysis (CVVH/D) has been the accepted modality in the developed world. Unfortunately, due to cost constraints, CVVH/D is often not available and peritoneal dialysis (PD) remains the common mode of RRT in resource-poor facilities. Acute PD has its drawbacks, and intermittent HD (IHD) done slowly over a prolonged period has been explored as an alternative. Various modes of slow sustained IHD have been described in the literature with the recently introduced term prolonged intermittent RRT (PIRRT) serving as an umbrella terminology for all of these modes. PIRRT has been widely accepted in adults with studies showing it to be as effective as CVVH/D but with an added advantage of being more cost-effective. Pediatric data, though scanty, has been promising. In this current review, we elaborate on the practical aspects of undertaking PIRRT in children as well as summarize its current status.
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Affiliation(s)
- Rajiv Sinha
- Institute of Child Health and AMRI Hospital, 37, G Bondel Road, Kolkata, West Bengal, 700019, India.
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Timothy Bunchman
- Pediatric Nephrology, Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | - Valentine Lobo
- Department of Nephrology, KEM Hospital, Pune, Maharashtra, India
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Cleveland, OH, USA
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19
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Yu B, Adedoyin A, Hershberger E, Caro L, Xiao A, Rhee EG, Huntington JA. Safety, Tolerability, and Pharmacokinetics of 3 g of Ceftolozane/Tazobactam in Healthy Adults: A Randomized, Placebo-Controlled, Multiple-Dose Study. Clin Pharmacol Drug Dev 2018. [PMID: 29517862 DOI: 10.1002/cpdd.429] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Ceftolozane/tazobactam is an antibacterial approved at 1.5 g (1g/0.5 g) every 8 hours (q8h); higher doses may provide additional benefits in difficult-to-treat infections. We conducted a phase I trial in healthy adults evaluating safety, tolerability, and pharmacokinetics of 3 g (2 g/1 g) ceftolozane/tazobactam administered q8h for 10 days. Sixteen participants were randomized (2:1:1) to 3 g ceftolozane/tazobactam, 1.5 g ceftolozane/tazobactam, or placebo. Participants underwent regular safety and plasma drug level assessments, with a follow-up safety visit 7 days after completion. No adverse events (AEs) were reported with placebo; 75% of participants in the 1.5-g and 50% in the 3-g arm experienced AEs. AE types were similar between the ceftolozane/tazobactam groups; all AEs were mild. No participants experienced clinically meaningful laboratory assessment or electrocardiogram abnormalities. Both ceftolozane and tazobactam exhibited dose-proportional pharmacokinetics without accumulation and without substantial differences in clearance and volume of distribution between groups. In the 3-g group, mean ceftolozane parameters were: peak concentration 104 μg/mL (day 1), 112 μg/mL (day 10); half-life 3 hours (day 10); area under the concentration-time curve (AUC(0-t) ) 272 μg·h/mL (day 1), 300μg·h/mL (day 10). Mean tazobactam parameters were: peak concentration 28 μg/mL (day 1), 26 μg/mL (day 10); half-life 1 hour (day 10); AUC(0-t) 47μg·h/mL (day 1), 41μg·h/mL (day 10). Administration of 3 g ceftolozane/tazobactam q8h for 10 days was safe and well tolerated in healthy volunteers.
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Affiliation(s)
- Brian Yu
- Merck & Co, Inc, Kenilworth, NJ, USA
| | | | | | | | - Alan Xiao
- Merck & Co, Inc, Kenilworth, NJ, USA
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20
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König C, Braune S, Roberts JA, Nierhaus A, Steinmetz OM, Baehr M, Frey OR, Langebrake C, Kluge S. Population pharmacokinetics and dosing simulations of ceftazidime in critically ill patients receiving sustained low-efficiency dialysis. J Antimicrob Chemother 2018; 72:1433-1440. [PMID: 28175308 DOI: 10.1093/jac/dkw592] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 12/29/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives To describe the population PKs of ceftazidime in critically ill patients receiving sustained low-efficiency dialysis (SLED). Patients and methods This study was performed in ICUs of a university hospital. We collected blood samples during three consecutive days of SLED sessions in patients receiving ceftazidime. Concentration versus time curves were analysed using a population PKs approach with Pmetrics ® . Monte Carlo simulation for the first 24 h including a 6 h SLED session was performed with the final model. The fractional target attainment against the MIC of Pseudomonas aeruginosa was executed using targets of 50 and 100% fT > MIC . Results In total, 211 blood samples of 16 critically ill patients under SLED were collected. SLED treatments were 299.3 (68.4) min in duration. A two-compartment linear population PK model was most appropriate. The mean (SD) CL of ceftazidime on SLED, and off SLED were 5.32 (3.2), 1.06 (1.0) L/h respectively. The PTA for 50% fT > MIC for a dose of 1 g intravenously every 8 h was 98%. Assuming a target of 100% fT > MIC a dose of 2 g every 12 h covers isolates with MIC ≤8 mg/L with a PTA of 96%. Conclusion In critically ill patients receiving SLED, ceftazidime 1 g every 8 h and ceftazidime 2 g every 12 h appear to be sufficient for achieving traditional (50% fT > MIC ) and aggressive PD targets (100% fT > MIC ) for susceptible isolates (MIC ≤8 mg/L), respectively.
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Affiliation(s)
- Christina König
- Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stephan Braune
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jason A Roberts
- Burns, Trauma, and Critical Care Research Centre and Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Australia
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver M Steinmetz
- University Medical Center Hamburg-Eppendorf, Department of Internal Medicine III. (Nephrology/Rheumatology with Section Endocrinology), Hamburg, Germany
| | - Michael Baehr
- Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Otto R Frey
- Hospital Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Claudia Langebrake
- Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
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Mei JP, Ali-Moghaddam A, Mueller BA. Survey of pharmacists’ antibiotic dosing recommendations for sustained low-efficiency dialysis. Int J Clin Pharm 2016; 38:127-34. [PMID: 26499505 DOI: 10.1007/s11096-015-0214-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/15/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of hybrid renal replacement therapies like sustained low efficiency dialysis (SLED) is increasing in ICUs worldwide. However, pharmacokinetic studies designed to inform therapeutic antibiotic dosing in critically ill patients receiving SLED are limited. SLED operational characteristics vary across institutions. Pharmacists in institutions that utilize SLED are challenged to recommend therapeutic doses for antibiotics. OBJECTIVE To characterize pharmacist-recommended antibiotic regimens for SLED. METHODS An electronic survey was sent to pharmacist members of the American College of Clinical Pharmacy in the Nephrology or Critical Care Practice and Research Network. Dosing recommendations for a hypothetical critically ill septic patient were collected for cefepime, ceftaroline, daptomycin, levofloxacin, meropenem, and piperacillin/tazobactam. Main outcome measure Antibiotic regimens for the six antibiotics, their frequency, pharmacist’s experience with renal replacement therapies (RRT), post-graduate training, years of clinical experience, number of staffed beds in their hospital, and RRT employed in their ICUs. RESULTS The survey was completed by 69 clinical pharmacists who had 8.5 ± 7.5 (mean ± SD) years of experience. All pharmacists had experience dosing medications for patients receiving RRT. The most frequently recommended regimen for each antibiotic was: cefepime 1000 mg every 24 h, ceftaroline 200 mg every 12 h, daptomycin 6 mg/kg every 24 h, levofloxacin 500 mg every 24 h, meropenem 1000 mg every 12 h, and piperacillin/tazobactam 2250 mg every 8 h. Up to nine distinct regimens were recommended for each antibiotic, and the total daily dose between these regimens ranged by as much as a 12-fold. Neither pharmacist’s experience with SLED, post-graduate training, nor years of clinical experience were significantly associated with particular dosing recommendations for the antibiotics. CONCLUSION Pharmacists working in institutions that utilize SLED make antibiotic dosing recommendations that vary 4–12-fold depending on the drug. Published research does not provide adequate guidance to optimally dose antibiotics in patients receiving SLED. More SLED pharmacokinetic trials, real-time serum concentration monitoring and advanced pharmacokinetic modeling techniques are necessary to ensure therapeutic dosing in patients receiving SLED.
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Edrees F, Li T, Vijayan A. Prolonged Intermittent Renal Replacement Therapy. Adv Chronic Kidney Dis 2016; 23:195-202. [PMID: 27113696 DOI: 10.1053/j.ackd.2016.03.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 12/29/2022]
Abstract
Prolonged intermittent renal replacement therapy (PIRRT) is becoming an increasingly popular alternative to continuous renal replacement therapy in critically ill patients with acute kidney injury. There are significant practice variations in the provision of PIRRT across institutions, with respect to prescription, technology, and delivery of therapy. Clinical trials have generally demonstrated that PIRRT is non-inferior to continuous renal replacement therapy regarding patient outcomes. PIRRT offers cost-effective renal replacement therapy along with other advantages such as early patient mobilization and decreased nursing time. However, due to lack of standardization of the procedure, PIRRT still poses significant challenges, especially pertaining to appropriate drug dosing. Future guidelines and clinical trials should work toward developing consensus definitions for PIRRT and ensure optimal delivery of therapy.
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How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy? Diagn Microbiol Infect Dis 2015; 82:92-103. [PMID: 25698632 DOI: 10.1016/j.diagmicrobio.2015.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 12/28/2014] [Accepted: 01/25/2015] [Indexed: 12/30/2022]
Abstract
Determining appropriate antibiotic dosing for critically ill patients receiving renal replacement therapy (RRT) is complex. Worldwide unstandardized and heterogeneous prescribing of RRT as well as altered patient physiology and pathogen susceptibility all cause drug disposition to be much different to that seen in non-critically ill patients. Significant changes to pharmacokinetic parameters, including volume of distribution and clearance, could be expected, in particular, for antibiotics that are hydrophilic with low plasma protein binding and that are usually primarily eliminated by the renal system. Antibiotic clearance is likely to be significantly increased when higher RRT intensities are used. The combined effect of these factors that alter antibiotic disposition is that non-standard dosing strategies should be considered to achieve therapeutic exposure. In particular, an aggressive early approach to dosing should be considered and this may include administration of a 'loading dose', to rapidly achieve therapeutic concentrations and maximally reduce the inoculum of the pathogen. This approach is particularly important given the pharmacokinetic changes in the critically ill as well as the increased likelihood of less susceptible pathogens. Dose individualization that applies knowledge of the RRT and patient factors causing altered pharmacokinetics remains the key approach for ensuring effective antibiotic therapy for these patients. Where possible, therapeutic drug monitoring should also be used to ensure more accurate therapy. A lack of pharmacokinetic data for antibiotics during the prolonged intermittent RRT and intermittent hemodialysis currently limits evidence-based antibiotic dose recommendations for these patients.
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Jiang SP, Xu YY, Wu WF, Zhang XG, Lu XY, Xiao YH, Liang WF, Chen J. Improving antimicrobial dosing in critically ill patients receiving continuous venovenous hemofiltration and the effect of pharmacist dosing adjustment. Eur J Intern Med 2014; 25:930-5. [PMID: 25153537 DOI: 10.1016/j.ejim.2014.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 07/28/2014] [Accepted: 08/01/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Appropriate antimicrobial dosing for patients receiving continuous venovenous hemofiltration (CVVH) is complex. Pharmacist participation in antimicrobial dosing adjustment for patients receiving CVVH may be advantageous. METHODS A comparative study was performed in a China hospital intensive care unit (ICU).Patients receiving CVVH in the intervention group received antimicrobial dosing adjustment service by pharmacists from January 2012 to June 2012, whereas patients in the control group received routine medical care between July 2012 and December 2012. The primary outcomes including patients' length of ICU stay, mortality in ICU, ICU hospitalization costs, and the occurrence of adverse drug events (ADEs) were then compared. RESULTS 87 and 93 patients were included in the control and intervention groups. During the intervention period, pharmacists made 256 antimicrobial dosing adjustment recommendations for 93 enrolled patients receiving CVVH, of which 224 (87.5%) recommendations were accepted by physicians. Changing in CVVH-related variables (175, 68.4%) were the most common risk factors for dosing errors, whereas β-lactams (131, 51.2%) were the most frequency of antimicrobials associated with dosing errors. Compared with the control group, pharmacist dosing adjustment resulted in £1637.7 cost savings per patient, and 2.36 times reduction of antimicrobial-related adverse drug events (ADEs) (11 vs 26, P=0.002), while length of ICU stay and mortality in ICU showed no significant difference (P>0.05). CONCLUSIONS The involvement of pharmacist to participate in the ICU team rounds for patients receiving CVVH is associated with cost savings and reduction of ADEs. Hospital may consider employing ICU pharmacists.
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Affiliation(s)
- Sai-Ping Jiang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Yan-Yan Xu
- Department of Pharmacy, Lishui central Hospital, 289 Kuocang Road, Lishui 323000, P.R. China
| | - Wei-Fang Wu
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Xing-Guo Zhang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Xiao-Yang Lu
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China
| | - Yong-Hong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, P.R. China
| | - Wei-Feng Liang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, P.R. China
| | - Jian Chen
- Intensive Care Unit, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou 310003, P.R. China.
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Clark EG, Bagshaw SM. Unnecessary Renal Replacement Therapy for Acute Kidney Injury is Harmful for Renal Recovery. Semin Dial 2014; 28:6-11. [DOI: 10.1111/sdi.12300] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Edward G. Clark
- Kidney Research Centre; Ottawa Hospital Research Institute; University of Ottawa and Division of Nephrology; The Ottawa Hospital; Ottawa Ontario Canada
| | - Sean M. Bagshaw
- Division of Critical Care Medicine; Faculty of Medicine and Dentistry; University of Alberta; Edmonton Canada
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Medikamentendosierung unter extrakorporaler Therapie. Med Klin Intensivmed Notfmed 2014; 109:348-53. [DOI: 10.1007/s00063-014-0349-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
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Wong G, Brinkman A, Benefield RJ, Carlier M, De Waele JJ, El Helali N, Frey O, Harbarth S, Huttner A, McWhinney B, Misset B, Pea F, Preisenberger J, Roberts MS, Robertson TA, Roehr A, Sime FB, Taccone FS, Ungerer JPJ, Lipman J, Roberts JA. An international, multicentre survey of -lactam antibiotic therapeutic drug monitoring practice in intensive care units. J Antimicrob Chemother 2014; 69:1416-23. [DOI: 10.1093/jac/dkt523] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Chant C, Leung A, Friedrich JO. Optimal dosing of antibiotics in critically ill patients by using continuous/extended infusions: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R279. [PMID: 24289230 PMCID: PMC4056781 DOI: 10.1186/cc13134] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 11/13/2013] [Indexed: 01/07/2023]
Abstract
Introduction The aim of this study was to determine whether using pharmacodynamic-based dosing of antimicrobials, such as extended/continuous infusions, in critically ill patients is associated with improved outcomes as compared with traditional dosing methods. Methods We searched Medline, HealthStar, EMBASE, Cochrane Clinical Trial Registry, and CINAHL from inception to September 2013 without language restrictions for studies comparing the use of extended/continuous infusions with traditional dosing. Two authors independently selected studies, extracted data on methodology and outcomes, and performed quality assessment. Meta-analyses were performed by using random-effects models. Results Of 1,319 citations, 13 randomized controlled trials (RCTs) (n = 782 patients) and 13 cohort studies (n = 2,117 patients) met the inclusion criteria. Compared with traditional non-pharmacodynamic-based dosing, RCTs of continuous/extended infusions significantly reduced clinical failure rates (relative risk (RR) 0.68; 95% confidence interval (CI) 0.49 to 0.94, P = 0.02) and intensive care unit length of stay (mean difference, −1.5; 95% CI, −2.8 to −0.2 days, P = 0.02), but not mortality (RR, 0.87; 95% CI, 0.64 to 1.19; P = 0.38). No significant between-trial heterogeneity was found for these analyses (I2 = 0). Reduced mortality rates almost achieved statistical significance when the results of all included studies (RCTs and cohort studies) were pooled (RR, 0.83; 95% CI, 0.69 to 1.00; P = 0.054). Conclusions Pooled results from small RCTs suggest reduced clinical failure rates and intensive care unit length-of-stay when using continuous/extended infusions of antibiotics in critically ill patients. Reduced mortality rates almost achieved statistical significance when the results of RCTs were combined with cohort studies. These results support the conduct of adequately powered RCTs to define better the utility of continuous/extended infusions in the era of antibiotic resistance.
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Drug use and nephrotoxicity in the intensive care unit: are we under-dosing antimicrobials in patients with acute kidney injury with the need of extended dialysis? Kidney Int 2013; 82:935-6; author reply 936-7. [PMID: 23018830 DOI: 10.1038/ki.2012.285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Clajus C, Kühn-Velten WN, Schmidt JJ, Lorenzen JM, Pietsch D, Beutel G, Kielstein JT. Cotrimoxazole plasma levels, dialyzer clearance and total removal by extended dialysis in a patient with acute kidney injury: risk of under-dosing using current dosing recommendations. BMC Pharmacol Toxicol 2013; 14:19. [PMID: 23551893 PMCID: PMC3626772 DOI: 10.1186/2050-6511-14-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 03/20/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Dosing of antibiotics in critically ill patients is challenging. It becomes even more difficult if renal or hepatic impairment ensue. Modern means of renal replacement therapy are capable of removing antibiotics to a higher rate than decades ago, leaving clinicians with a high degree of uncertainty concerning the dose of antibiotics in this patient population. Cotrimoxazole, a combination of trimethoprim (TMP) and sulfamethoxazole (SMX) is frequently used in the treatment of several infections including Pneumocystis jirovecii pneumonia (PCP). CASE PRESENTATION Here we describe a patient with acute kidney injury in which we investigated the TMP and SMX levels during the course of an ICU stay. Cotrimoxazole was administered every six hours i.v. in a dose of TMP/SMX 15/75 mg/kg/day. Extended dialysis was performed with a high-flux dialyzer. Blood samples, as well as pre- and postdialyzer samples and aliquots of the collected spent dialysate were collected.Observed peak concentrations (Cmax) were 7.51 mg/l for TMP and 80.80 mg/l for SMX. Decline of blood levels during extended dialysis (TMP 64%; SMX 84%) was mainly due to removal by the dialysis procedure, illustrated by the high dialyzer clearances (median of 4 extended dialysis sessions: TMP 94.0 / SMX 51.0 ml/min), as well as by the absolute amount of both substances in the collected spent dialysate (median of 6 extended dialysis sessions: TMP 556 mg / SMX 130 mg). Within the limitation of a case report our data from 4 consecutive extended dialysis sessions suggest that this procedure substantially removes both TMP and SMX. CONCLUSIONS Dose reduction, which is usually advocated in patients with acute kidney injury under renal replacement therapy, might lead to significant under-dosing. Pharmacokinetic studies for TMP/SMX dosing in this patient population are necessary to allow adequate dosing.
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Affiliation(s)
- Christian Clajus
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
| | | | - Julius J Schmidt
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
| | - Johan M Lorenzen
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
| | - Daniel Pietsch
- Institute of Clinical Chemistry, Medical School Hannover, Hannover, Germany
| | - Gernot Beutel
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Medical School Hannover, Hannover, Germany
| | - Jan T Kielstein
- Department of Nephrology and Hypertension, Medical School Hannover, Hannover, Germany
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Scoville BA, Mueller BA. Medication Dosing in Critically Ill Patients With Acute Kidney Injury Treated With Renal Replacement Therapy. Am J Kidney Dis 2013; 61:490-500. [DOI: 10.1053/j.ajkd.2012.08.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 08/28/2012] [Indexed: 12/20/2022]
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Fissell WH. Antimicrobial dosing in acute renal replacement. Adv Chronic Kidney Dis 2013; 20:85-93. [PMID: 23265600 DOI: 10.1053/j.ackd.2012.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 10/11/2012] [Accepted: 10/11/2012] [Indexed: 12/28/2022]
Abstract
Acute kidney injury (AKI) is a common problem in hospitalized patients and is associated with significant morbidity and mortality. Two large trials showed no benefit from increased doses of renal replacement therapy (RRT) despite previous clinical data suggesting that increased clearance from RRT has beneficial effects. Since infection is the leading cause of death in AKI, my group and others hypothesized that increased RRT antibiotic clearance might create a competing morbidity. The data from my group, as well as those of other groups, show that many patients are underdosed when routine "1 size fits all" antibiotic dosing is used in patients with AKI receiving continuous RRT (CRRT). Here, concepts of drug distribution and clearance in AKI are briefly discussed and then 1 antibiotic (piperacillin) is discussed in depth to illustrate the challenges in applying the medical literature to clinical practice. The fact that published data on drug dosing in AKI and dialysis reflect the evolution of practice patterns and often do not apply to present prescribing habits is also discussed. A more general approach to drug dosing facilitates situation-specific prescribing by the nephrologist and critical care specialist.
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Martino F, Lorenzen J, Schmidt J, Schmidt M, Broll M, Görzig Y, Kielstein JT, Thum T. Circulating microRNAs are not eliminated by hemodialysis. PLoS One 2012; 7:e38269. [PMID: 22715378 PMCID: PMC3371001 DOI: 10.1371/journal.pone.0038269] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 05/07/2012] [Indexed: 01/02/2023] Open
Abstract
Background Circulating microRNAs are stably detectable in serum/plasma and other body fluids. In patients with acute kidney injury on dialysis therapy changes of miRNA patterns had been detected. It remains unclear if and how the dialysis procedure itself affects circulating microRNA level. Methods We quantified miR-21 and miR-210 by quantitative RT-PCR in plasma of patients with acute kidney injury requiring dialysis and measured pre- and post-dialyser miRNA levels as well as their amount in the collected spent dialysate. Single treatments using the following filters were studied: F60 S (1.3 m2, Molecular Weight Cut Off (MWCO): 30 kDa, n = 8), AV 1000 S (1.8 m2, MWCO: 30 kDa, n = 6) and EMiC 2 (1.8 m2, MWCO: 40 kDa, n = 6). Results Circulating levels of miR-21 or -210 do not differ between pre- and post-dialyzer blood samples independently of the used filter surface and pore size: miR-21: F60S: p = 0.35, AV 1000 S p = 1.0, EMiC2 p = 1.0; miR-210: F60S: p = 0.91, AV 1000 S p = 0.09, EMiC2 p = 0.31. Correspondingly, only traces of both miRNAs could be found in the collected spent dialysate and ultrafiltrate. Conclusions In patients with acute kidney injury circulating microRNAs are not removed by dialysis. As only traces of miR-21 and -210 are detected in dialysate and ultrafiltrate, microRNAs in the circulation are likely to be transported by larger structures such as proteins and/or microvesicles. As miRNAs are not affected by dialysis they might be more robust biomarkers of acute kidney injury.
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Affiliation(s)
- Filippo Martino
- Institute for Molecular and Translational Treatment Strategies (IMTTS), Hannover Medical School, Hannover, Germany
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35
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Mueller BA, Scoville BA. Adding to the Armamentarium: Antibiotic Dosing in Extended Dialysis. Clin J Am Soc Nephrol 2012; 7:373-5. [DOI: 10.2215/cjn.00650112] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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