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Pharmacokinetic Model for Cefuroxime Dosing during Cardiac Surgery under Cardiopulmonary Bypass. Antimicrob Agents Chemother 2020; 64:AAC.01687-20. [PMID: 33020154 DOI: 10.1128/aac.01687-20] [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: 08/05/2020] [Accepted: 09/24/2020] [Indexed: 12/17/2022] Open
Abstract
Cefuroxime (CXM) is an antibiotic recommended for surgical site infection prevention in cardiac surgery. However, the dosing regimens commonly used do not sustain therapeutic concentrations throughout surgery. The aim of this study was to conduct a population analysis of CXM pharmacokinetics (PK), and to propose an optimized dosing regimen. Adult patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) received a 1,500 mg CXM intravenous bolus followed by a 750 mg bolus at CPB priming, then every 2 h thereafter. Model-based PK simulations were used to develop an optimized dosing regimen and evaluate its efficacy in attaining various concentration thresholds, including those recommended in US and European guidelines. In total, 447 CXM measurements were acquired in 50 patients. A two-compartment model best fit the data, with total body weight and creatinine clearance determining interpatient variability in the central and peripheral volumes of distribution, and in elimination clearance, respectively. Using our optimized dosing regimen, different dosing schemes adapted to body weight and renal function were calculated to attain total concentration thresholds ranging from 12 to 96 mg/liter. Our simulations showed that the dosing regimens recommended in US and European guidelines failed to maintain concentrations above 48 mg/liter. Our individualized dosing strategy was capable of ensuring therapeutic CXM concentrations conforming to each target threshold. Our model yielded an optimized CXM dosing regimen adapted to body weight and renal function, and sustaining therapeutic concentrations consistent with each desired threshold. The optimal target concentration and necessary duration of its maintenance in cardiac surgery still remain unclear.
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Spindler N, Biereigel C, Pieroh P, Schroeter T, Misfeld M, Josten C, Borger M, Rodloff AC, Langer S. Clinical and Microbiological Analysis of Deep Sternal Wound Infections in Fifty-Two Consecutive Patients. Surg Infect (Larchmt) 2019; 21:370-377. [PMID: 31809233 DOI: 10.1089/sur.2018.300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Mediastinitis after cardiac surgery can lead to devastating consequences such as deep sternal wound infections (DSWI). Staphylococcus epidermidis and other coagulase-negative staphylococci belong to the physiological skin flora and therefore generally are not considered pathogenic agents. Thus, local resistance patterns of these bacterial species often recovered from wound specimens generally are ignored while choosing antibiotics for peri-operative prophylaxis in cardiac surgery as well as in the selection of empiric antibiotic therapy of DSWI. Methods: During the period May 2012-May 2013, 52 patients suffering from DSWI were treated at our institution. For every patient, deep tissue samples were obtained during surgical debridement procedures and submitted to microbiologic analysis. The frequency of and the time to occurrence of a DSWI was recorded, and baseline data, previous operative interventions, complications, and the technique used for soft tissue reconstruction, as well as the microbiologic results and individual risk factors, were documented. Results: There were 32 male patients (62%) and 20 female. The patients' age at the time of revision was a mean of 67 ± 11.5 years (range 35-83 years). There was bacterial growth in 31 cases (60%), the predominant species being S. epidermidis (20 patients; 65%). Extended antibiotic therapy was indispensable to controlling the infection. Conclusion: The local resistance patterns of antibiotics should have a greater influence on the standardized prophylaxis or empirical therapy of DSWI and need to be discussed specifically for this high-risk population. Because of its multi-resistance spectrum, S. epidermidis must be classified as a potential pathogen. In the cases reported here, extended antibiotic therapy was necessary to support wound healing and thus good patient outcomes.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
| | - Corinna Biereigel
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
| | - Phillipp Pieroh
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany.,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thomas Schroeter
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Arne C Rodloff
- Institute of Microbiology and Epidemiology of Infectious Diseases, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology, and Plastic Surgery and University Hospital Leipzig, Leipzig, Germany
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Skhirtladze-Dworschak K, Hutschala D, Reining G, Dittrich P, Bartunek A, Dworschak M, Tschernko EM. Cefuroxime plasma and tissue concentrations in patients undergoing elective cardiac surgery: Continuous vs bolus application. A pilot study. Br J Clin Pharmacol 2019; 85:818-826. [PMID: 30636060 PMCID: PMC6422641 DOI: 10.1111/bcp.13865] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 12/12/2018] [Accepted: 12/29/2018] [Indexed: 01/01/2023] Open
Abstract
Aims Surgical site infections contribute to morbidity and mortality after surgery. The authors hypothesized that higher antibiotic tissue concentrations can be reached for a prolonged time span by continuous administration of prophylactic cefuroxime compared to bolus administration. Methods Twelve patients undergoing elective cardiac surgery were investigated. Group A received 1.5 g cefuroxime as bolus infusions before surgery, and 12 and 24 hours thereafter. In group B, a continuous infusion of 3.0 g cefuroxime was started after a bolus of 1.5 g. Cefuroxim levels were determined in blood and tissue (microdialysis). T‐test, Wilcoxon signed rank test and χ2 test were used for statistical analysis. Results The area under the curve (AUC) of plasma cefuroxime concentrations was greater in group B (399 [333–518]) as compared to group A (257 [177–297] h mg L−1, [median and interquartile range], P = .026). Furthermore, a significantly longer percentage of time > minimal inhibitory concentrations of 2 mg L−1 (100% vs 50%), 4 mg L−1 (100% vs 42%), 8 mg L−1 (100% vs 17%) and 16 mg L−1 (83% vs 8%) was found for free plasma cefuroxime in group B. In group B, area under the curve in subcutaneous tissue (78 [61–113] h mg L−1) and median peak concentration (33 [26–38] mg L−1) were markedly higher compared to group A (P = 0.041 and P = .026, respectively). Conclusions Higher cefuroxime concentrations were measured in plasma and subcutaneously over a prolonged period of time when cefuroxime was administered continuously. The clinical implication of this finding still has to be elucidated.
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Affiliation(s)
- Keso Skhirtladze-Dworschak
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
| | - Doris Hutschala
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
| | - Georg Reining
- Department of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
| | - Peter Dittrich
- Institute of Pharmaceutical Sciences, Department of Pharmacology and Toxicology, University of Graz, Austria
| | - Anna Bartunek
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
| | - Edda M Tschernko
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Austria
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Population Pharmacokinetic Model-Based Evaluation of Standard Dosing Regimens for Cefuroxime Used in Coronary Artery Bypass Graft Surgery with Cardiopulmonary Bypass. Antimicrob Agents Chemother 2018; 62:AAC.02241-17. [PMID: 29358296 DOI: 10.1128/aac.02241-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 01/09/2018] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study was to investigate the population pharmacokinetics (PK) of cefuroxime in patients undergoing coronary artery bypass graft (CABG) surgery. In this observational pharmacokinetic study, multiple blood samples were collected over a 48-h interval of intravenous cefuroxime administration. The samples were analyzed by using a validated high-performance liquid chromatography (HPLC) method. Population pharmacokinetic models were developed using Monolix (version 4.4) software. Pharmacokinetic-pharmacodynamic (PD) simulations were performed to explore the ability of different dosage regimens to achieve the pharmacodynamic targets. A total of 468 blood samples from 78 patients were analyzed. The PK for cefuroxime were best described by a two-compartment model with between-subject variability on clearance, the volume of distribution of the central compartment, and the volume of distribution of the peripheral compartment. The clearance of cefuroxime was related to creatinine clearance (CLCR). Dosing simulations showed that standard dosing regimens of 1.5 g could achieve the PK-PD target of the percentage of the time that the free concentration is maintained above the MIC during a dosing interval (fTMIC) of 65% for an MIC of 8 mg/liter in patients with a CLCR of 30, 60, or 90 ml/min, whereas this dosing regimen failed to achieve the PK-PD target in patients with a CLCR of ≥125 ml/min. In conclusion, administration of standard doses of 1.5 g three times daily provided adequate antibiotic prophylaxis in patients undergoing CABG surgery. Lower doses failed to achieve the PK-PD target. Patients with high CLCR values required either higher doses or shorter intervals of cefuroxime dosing. On the other hand, lower doses (1 g three times daily) produced adequate target attainment for patients with low CLCR values (≤30 ml/min).
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Wetzstein N, Brodt HR. Perioperative Antiinfektivaprophylaxe in der Kardiochirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-015-0056-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Targeting cefuroxime plasma concentrations during coronary artery bypass graft surgery with cardiopulmonary bypass. Int J Clin Pharm 2015; 37:592-8. [DOI: 10.1007/s11096-015-0101-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 03/10/2015] [Indexed: 10/23/2022]
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Jonsson TB, Nilsson TK, Breimer LH, Schneede J, Arfvidsson B, Norgren L. Cloxacillin concentrations in serum, subcutaneous fat, and muscle in patients with chronic critical limb ischemia. Eur J Clin Pharmacol 2014; 70:957-63. [DOI: 10.1007/s00228-014-1695-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/02/2014] [Indexed: 12/01/2022]
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Huang JH, Sunstrom R, Munar MY, Cherala G, Legg A, Olyeai AJ, Langley SM. Are children undergoing cardiac surgery receiving antibiotics at subtherapeutic levels? J Thorac Cardiovasc Surg 2014; 148:1591-6. [PMID: 24521951 DOI: 10.1016/j.jtcvs.2013.12.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 12/04/2013] [Accepted: 12/24/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Perioperative antibiotics have decreased-but not eradicated-postoperative infections. In patients undergoing cardiac surgery with cardiopulmonary bypass, the dilutional effect of the priming and any additional volume given during the procedure may lead to subtherapeutic antibiotic levels. Our aim was to determine if children undergoing cardiac surgery with cardiopulmonary bypass receive perioperative antibiotics at subtherapeutic levels. METHODS Using published pharmacokinetic data on cefuroxime, we developed a computer simulation model to generate a nomogram predicting patients at risk for subtherapeutic cefuroxime levels based on time from initial dosing and additional volume given. RESULTS A computer-generated 1-compartment pharmacokinetic model was created to predict cefuroxime plasma levels over time for patients of all weights and additional volumes given for both a 25- and 50-mg/kg intravenous dose. For example, following a 25-mg/kg dose, a patient receiving an additional volume of 275 mL/kg is predicted to be subtherapeutic (<16 mg/L=4×minimum inhibitory concentration) at 4 hours. Our nomogram predicts all patients will be subtherapeutic at 8 hours, consistent with general pediatrics dosing schemes. Following a 50-mg/kg dose, levels are predicted to be subtherapeutic after an additional volume of 315 mL/kg at 5.5 hours. CONCLUSIONS Our model predicts which patients undergoing cardiac surgery with cardiopulmonary will have subtherapeutic cefuroxime levels. This nomogram enables providers to determine when to administer additional antibiotics in patients receiving large additional volumes during cardiac surgeries. This rational approach to perioperative antibiotic dosing may result in a reduction in postoperative infection in this vulnerable patient population.
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Affiliation(s)
- Jennifer H Huang
- Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health Science University, Portland, Ore.
| | - Rachel Sunstrom
- Division of Pediatric Cardiac Surgery, Oregon Health Science University, Doernbecher Children's Hospital, Portland, Ore
| | - Myrna Y Munar
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Ganesh Cherala
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Arthur Legg
- Division of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health Science University, Portland, Ore
| | - Ali J Olyeai
- College of Pharmacy, Oregon State University, Corvallis, Ore
| | - Stephen M Langley
- Division of Pediatric Cardiac Surgery, Oregon Health Science University, Doernbecher Children's Hospital, Portland, Ore
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Blood concentrations of cefuroxime in cardiopulmonary bypass surgery. Int J Clin Pharm 2013; 35:798-804. [DOI: 10.1007/s11096-013-9810-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 06/10/2013] [Indexed: 10/26/2022]
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Andreas M, Zeitlinger M, Hoeferl M, Jaeger W, Zimpfer D, Hiesmayr JM, Laufer G, Hutschala D. Internal mammary artery harvesting influences antibiotic penetration into presternal tissue. Ann Thorac Surg 2013; 95:1323-9; discussion 1329-30. [PMID: 23462262 DOI: 10.1016/j.athoracsur.2012.10.088] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 10/29/2012] [Accepted: 10/31/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Internal mammary artery (IMA) harvesting for coronary artery bypass grafting (CABG) influences tissue perfusion and represents a risk factor for deep sternal wound infection (DSWI). Cephalosporins are routinely administered for prophylaxis during cardiac operations to decrease perioperative wound infections. We hypothesized that mammary artery preparation impairs antibiotic penetration into presternal tissue during CABG. METHODS Eight patients undergoing skeletonized left mammary artery harvesting for CABG were included. Standard antibiotic prophylaxis was administered: 4 g of cefazolin before skin incision and an additional 2 g during skin closure. Concentrations of cefazolin were measured in subcutaneous tissue on the presternal right and left sides (surgically affected) after sternotomy and additionally in subcutaneous tissue on the thigh (surgically unaffected) by microdialysis over a 10-hour period. RESULTS Mean peak tissue concentration and the area under the curve (AUC) on the left sternal side were significantly reduced compared with the right side and compared with the thigh (mean peak concentration, 13.1±5.8 versus 24.1±4.7 and 27.8±9.7 μg/mL; p=0.005 and p=0.013; AUC 74.2±31.0 versus 110.4±25.0 and 140.3±46.3 μg×hours per milliliter; p=0.004 and p=0.002). Mean subcutaneous concentrations of cefazolin on the left sternal side exceeded the minimal inhibitory concentration (MIC90) of Staphylococcus epidermidis of 4 μg/mL in only 5 of 8 (37.5%) patients after 5 hours. CONCLUSIONS IMA harvesting significantly impairs local antibiotic penetration during CABG. Common antibiotic dosing schemas should be reevaluated in this cardiac surgical setting.
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Affiliation(s)
- Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Ferreira F, Santos S, Nascimento J, Strabelli T, Carmona M. Influence of cardiopulmonary bypass on cefuroxime plasma concentration and pharmacokinetics in patients undergoing coronary surgery. Eur J Cardiothorac Surg 2012; 42:300-5. [DOI: 10.1093/ejcts/ezr319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Zhao L, Zhao Y, Li Q, Chen X, Xiao F, He B, Wang J, Bi K. A fast, sensitive, and high throughput method for the determination of cefuroxime lysine in dog plasma by UPLC–MS/MS. Talanta 2012; 89:84-90. [DOI: 10.1016/j.talanta.2011.11.063] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 11/11/2011] [Accepted: 11/15/2011] [Indexed: 11/26/2022]
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