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Aberger S, Kolland M, Eller K, Rosenkranz AR, Kirsch AH. Differences in drug removal between standard high-flux and medium cut-off dialyzers in a case of severe vancomycin toxicity. Clin Kidney J 2024; 17:sfae063. [PMID: 38887428 PMCID: PMC11181855 DOI: 10.1093/ckj/sfae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Indexed: 06/20/2024] Open
Abstract
Vancomycin is a widely used glycopeptide antibiotic with the need for therapeutic drug monitoring to avoid renal toxicity. We report a case of severe vancomycin-associated anuric acute kidney injury managed with successful drug-removal by hemodialysis (HD) using different types of dialyzers. Medium cut-off (MCO) and high-flux dialyzers were effective in drug removal. Higher vancomycin elimination rate and lower plasma half-life were achieved with MCO dialyzer despite low-flow vascular access and intolerance to ultrafiltration. MCO dialyzers may be reasonable for drug removal in patients with intolerance of ultrafiltration, low-flow vascular access or impracticality of hemodiafiltration. Future studies should explore the use of MCO dialyzers in comparison with high-flux HD and hemodiafiltration in both the acute and chronic setting.
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Affiliation(s)
- Simon Aberger
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Internal Medicine I, Paracelsus Medical University, Salzburg, Austria
| | - Michael Kolland
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Kathrin Eller
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander R Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander H Kirsch
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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2
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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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3
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Lewis SJ, Jang SM, Mueller BA. Vancomycin and daptomycin dosing recommendations in patients receiving home hemodialysis using Monte Carlo simulation. BMC Nephrol 2023; 24:270. [PMID: 37710245 PMCID: PMC10500909 DOI: 10.1186/s12882-023-03314-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Few drug dosing recommendations for patients receiving home hemodialysis (HHD) have been published which has hindered the adoption of HHD. HHD regimens vary widely and differ considerably from conventional, thrice weekly, in-center hemodialysis in terms of treatment frequency, duration and blood and dialysate flow rates. Consequently, vancomycin and daptomycin clearances in HHD are also likely to be different, consequently HHD dosing regimens must be developed to ensure efficacy and minimize toxicity when these antibiotics are used. Many HHD regimens are used clinically, this study modeled ten common HHD regimens and determined optimal vancomycin and daptomycin dosing for each HHD regimen. METHODS Monte Carlo simulations using pharmacokinetic data derived from the literature and demographic data from a large HHD program treating patients with end stage kidney disease were incorporated into a one-compartment pharmacokinetic model. Virtual vancomycin and daptomycin doses were administered post-HHD and drug exposures were determined in 5,000 virtual patients receiving ten different HHD regimens. Serum concentration monitoring with subsequent dose changes was incorporated into the vancomycin models. Pharmacodynamic target attainment rates were determined for each studied dose. The lowest possible doses that met predefined targets in virtual patients were chosen as optimal doses. RESULTS HHD frequency, total dialysate volumes and HHD durations influenced drug exposure and led to different dosing regimens to meet targets. Antibiotic dosing regimens were identified that could meet targets for 3- and 7-h HHD regimens occurring every other day or 4-5 days/week. HHD regimens with 3-day interdialytic periods required higher doses prior to the 3-day period. The addition of vancomycin serum concentration monitoring allowed for calculation of necessary dosing changes which increased the number of virtual subjects meeting pharmacodynamic targets. CONCLUSIONS Doses of vancomycin and daptomycin that will meet desired pharmacodynamic targets in HHD are dependent on patient and HHD-specific factors. Doses used in conventional thrice weekly hemodialysis are unlikely to meet treatment goals. The antibiotic regimens paired with the HHD parameters studied in this analysis are likely to meet goals but require clinical validation.
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Affiliation(s)
- Susan J. Lewis
- University of Findlay College of Pharmacy, 1000 N. Main Street, Findlay, OH 45840 USA
- Mercy Health - St. Anne Hospital, Toledo, OH 43623 USA
| | - Soo Min Jang
- Proacture Consulting Group, 6905 Telegraph Rd, Bloomfield Hills, MI 48304 USA
| | - Bruce A. Mueller
- University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109-1065 USA
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Ito Y, Nakade J, Seki A, Gabata R, Okazaki M, Nakanuma S, Fujita A, Shimada T, Yamashita T, Yagi S, Taniguchi T, Sai Y. Case report: therapeutic monitoring of vancomycin in an acute liver failure patient with anuria under high-flow continuous hemodiafiltration. J Pharm Health Care Sci 2023; 9:15. [PMID: 37122008 PMCID: PMC10150540 DOI: 10.1186/s40780-023-00283-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/24/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND High-flow continuous hemodiafiltration (HF-CHDF) combines diffusive and convective solute removal and is employed for artificial liver adjuvant therapy. However, there is no report on dosage planning of vancomycin (VCM) in patients with acute liver failure under HF-CHDF. CASE PRESENTATION A 20-year-old woman (154 cm tall, weighing 50 kg) was transferred to the intensive care unit (ICU) with acute liver failure associated with autoimmune liver disease. On the following day, HF-CHDF was started due to elevated plasma ammonia concentration. On ICU day 8, VCM was started for suspected pneumonia and meningitis (30 mg/kg loading dose, then 20 mg/kg every 12 hrs). However, on ICU day 10, VCM blood concentration was under the limit of detection (< 3.0 μg/mL) and the patient developed anuria. The VCM dose was increased to 20 mg/kg every 6 hrs. Calculation with a one-compartment model using the HF-CHDF blood flow rate as a surrogate for VCM clearance, together with hematocrit and protein binding ratio, predicted a trough VCM blood concentration of 15 μg/mL. The observed concentration was about 12 μg/mL. The difference may represent non-HF-CHDF clearance. Finally, living donor liver transplantation was performed. CONCLUSION We report an acute liver failure patient with anuria under HF-CHDF in whom VCM administration failed to produce an effective blood concentration, likely due to HF-CHDF-enhanced clearance. VCM dosage adjustment proved successful, and was confirmed by calculation using a one-compartment model.
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Affiliation(s)
- Yuriko Ito
- Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Junya Nakade
- Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
- Department of Infection Control and Prevention, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Akihiro Seki
- Department of Gastroenterology, Graduate School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Ryosuke Gabata
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Mitsuyoshi Okazaki
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Shinichi Nakanuma
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Arimi Fujita
- Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Tsutomu Shimada
- Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Graduate School of Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Shintaro Yagi
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Graduate School of Medical Science, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Takumi Taniguchi
- Intensive Care Unit, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Yoshimichi Sai
- Department of Hospital Pharmacy, University Hospital, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
- Department of Clinical Pharmacokinetics, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
- AI Hospital/Macro Signal Dynamics Research and Development Center, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
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5
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Stitt G, Dubinsky S, Edginton A, Huang YSV, Zuppa AF, Watt K, Downes K. Antimicrobial Dosing Recommendations in Pediatric Continuous Renal Replacement Therapy: A Critical Appraisal of Current Evidence. Front Pediatr 2022; 10:889958. [PMID: 35633961 PMCID: PMC9134108 DOI: 10.3389/fped.2022.889958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/25/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Continuous renal replacement therapy (CRRT) is commonly employed in critically ill children and is known to affect antimicrobial pharmacokinetics. There is a lack of readily available, evidence-based antimicrobial dosing recommendations in pediatric CRRT. This study aims to quantify commonly used antimicrobial drugs in pediatric CRRT and identify gaps between contemporary literature-based dosing recommendations and those presented in a frequently used dosing reference. METHODS The Pediatric Health Information System (PHIS) database was queried from July 1, 2018 through June 30, 2021 to identify admissions in which antimicrobials were billed on the same day as CRRT. Drugs of interest were selected if at least 10% of admission involved administration on at least one CRRT day, with additional clinically important antimicrobials selected by the authors. A comprehensive literature search was performed to identify antimicrobial pharmacokinetic (PK) studies in children for each selected drug. For identified articles, dosing recommendations were extracted and compared to those in a popular tertiary dosing reference (Lexi-Comp Online database). The level of agreement of the dosing recommendations was assessed. RESULTS 77 unique antimicrobial agents were identified amongst 812 admissions from 20 different PHIS hospitals. Fifteen antimicrobials were billed on the same day as CRRT in ≥10% of admissions, with 4 additional drugs deemed clinically relevant by the authors. Twenty PK studies were identified for these 19 drugs, and dosing recommendations were included in 8 (42.1%) of them. Seventeen agents (89.5%) had some type of CRRT-specific dosing guidance in Lexi-Comp, with only 1 directly based on a pediatric CRRT study. For the 8 agents with PK data available, Lexi-Comp recommendations matched primary literature dosing guidance in 3 (37.5%). Two (25%) lacked agreement between the Lexi-Comp and primary literature, and the remaining 3 (37.5%) had partial agreement with multiple dosing regimens suggested in the primary literature and at least one of these regimens recommended by Lexi-Comp. CONCLUSION Significant gaps exist in the data supporting antimicrobial dosing recommendations for children receiving CRRT. Future studies should focus on antimicrobial dosing in pediatric CRRT, emphasizing provision of robust data from which dosing recommendations can be promptly incorporated into tertiary dosing references.
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Affiliation(s)
- Gideon Stitt
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Samuel Dubinsky
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Yuan-Shung V Huang
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Athena F Zuppa
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.,Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Kevin Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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6
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Farrar JE, Mueller SW, Stevens V, Kiser TH, Taleb S, Reynolds PM. Correlation of antimicrobial fraction unbound and sieving coefficient in critically ill patients on continuous renal replacement therapy: a systematic review. J Antimicrob Chemother 2021; 77:310-319. [DOI: 10.1093/jac/dkab396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/06/2021] [Indexed: 12/20/2022] Open
Abstract
Abstract
Background
Fraction unbound has been used as a surrogate for antimicrobial sieving coefficient (SC) to predict extracorporeal clearance in critically ill patients on continuous renal replacement therapy (CRRT), but this is based largely on expert opinion.
Objectives
To examine relationships between package insert-derived fraction unbound (Fu-P), study-specific fraction unbound (Fu-S), and SC in critically ill patients receiving CRRT.
Methods
English-language studies containing patient-specific in vivo pharmacokinetic parameters for antimicrobials in critically ill patients requiring CRRT were included. The primary outcome included correlations between Fu-S, Fu-P, and SC. Secondary outcomes included correlations across protein binding quartiles, serum albumin, and predicted in-hospital mortality, and identification of predictors for SC through multivariable analysis.
Results
Eighty-nine studies including 32 antimicrobials were included for analysis. SC was moderately correlated to Fu-S (R2 = 0.55, P < 0.001) and Fu-P (R2 = 0.41, P < 0.001). SC was best correlated to Fu-S in first (<69%) and fourth (>92%) quartiles of fraction unbound and above median albumin concentrations of 24.5 g/L (R2 = 0.71, P = 0.07). Conversely, correlation was weaker in patients with mortality estimates greater than the median of 55% (R2 = 0.06, P = 0.84). SC and Fu-P were also best correlated in the first quartile of antimicrobial fraction unbound (R2 = 0.66, P < 0.001). Increasing Fu-P, flow rate, membrane surface area, and serum albumin, and decreasing physiologic charge significantly predicted increasing SC.
Conclusions
Fu-S and Fu-P were both reasonably correlated to SC. Caution should be taken when using Fu-S to calculate extracorporeal clearance in antimicrobials with 69%–92% fraction unbound or with >55% estimated in-hospital patient mortality. Fu-P may serve as a rudimentary surrogate for SC when Fu-S is unavailable.
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Affiliation(s)
- Julie E. Farrar
- Auburn University Harrison School of Pharmacy, 650 Clinic Dr, Mobile, AL 36688, USA
| | - Scott W. Mueller
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Victoria Stevens
- University of Colorado Hospital, 12505 E 16th Ave, Aurora, CO 80045, USA
| | - Tyree H. Kiser
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Sim Taleb
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
| | - Paul M. Reynolds
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 12850 E. Montview Blvd, Aurora, CO 80045, USA
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Hartinger JM, Šíma M, Hronová K, Halouzková BA, Szonowská B, Polakovič V, Bednářová V, Hladinová Z, Tesař V, Slanař O. Vancomycin pharmacokinetics in patients treated with intermittent haemodialysis based on therapeutic drug monitoring. J Chemother 2021; 34:149-156. [PMID: 34551680 DOI: 10.1080/1120009x.2021.1979747] [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] [Indexed: 10/20/2022]
Abstract
Vancomycin is frequently used in haemodialysis (HD) patients but generally accepted target serum ranges and dosing strategy are still lacking in this group. Based on retrospective analysis of data from 118 HD patients treated with vancomycin the interdialytic elimination constant (Ke), apparent volume of distribution (Vd) and dialysis efficacy were calculated. The influence of possible clinical variables on the pharmacokinetic parameters of vancomycin have been tested. The median of Ke in interdialytic periods, corresponding half-life and Vd were 0.0073 h-1, 95.0 h and 0.87 L/kg, respectively. We found significant positive correlation between time in dialysis program and Ke. The Vd correlated best with lean body mass (LBM). For high- and low flux membrane HD of 4 hours duration the decline in vancomycin levels was 20.88% and 12.86%, respectively. Based on these data loading dose for vancomycin in HD patient should be calculated as 24.483 × LBM (kg) + 455 mg. The utility of this equation for entire HD population should be also verified prospectively.
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Affiliation(s)
- Jan Miroslav Hartinger
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Martin Šíma
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Karolína Hronová
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Barbora Agátha Halouzková
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Barbora Szonowská
- Internal Department of Strahov, General University Hospital in Prague, Prague, Czech Republic
| | - Vladimír Polakovič
- Internal Department of Strahov, General University Hospital in Prague, Prague, Czech Republic
| | - Vladimíra Bednářová
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Zuzana Hladinová
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ondřej Slanař
- Department of Clinical Pharmacology and Pharmacy, Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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Rider TR, Silinskie KM, Hite MS, Bress J. Pharmacokinetics of Vancomycin in Critically Ill Patients Undergoing Sustained Low-Efficiency Dialysis. Pharmacotherapy 2020; 40:1036-1041. [PMID: 32866291 DOI: 10.1002/phar.2460] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Vancomycin pharmacokinetic data in critically ill patients receiving sustained low-efficiency dialysis (SLED) is limited. Published data using vancomycin with intermittent hemodialysis and continuous renal replacement therapy may not be applicable to hybrid dialysis modalities such as SLED. Current drug references lack recommendations for vancomycin dosing in patients receiving SLED. OBJECTIVE The objective of this study was to determine vancomycin pharmacokinetics during SLED. METHODS A total of 20 patients who were critically ill with oliguric or anuric renal failure who received vancomycin and SLED were included in the study. Surrounding one SLED session, serum vancomycin blood samples were drawn before the initiation of SLED, at the termination of SLED, and 4 hours after completion of SLED treatment. Following this, patients received vancomycin, dosed to target a goal peak of 20-30 mcg/ml. A vancomycin peak level was drawn 1 hour after the end of the infusion. SLED treatment duration was at least 7 hours. Continuous data are reported as median (interquartile range) and categorical data as percentage. RESULTS The vancomycin elimination rate and half-life were 0.051 hours (0.042-0.074 hours) and 13.6 hours (9.4-16.6 hours), respectively. SLED reduced vancomycin serum concentrations by 35.4% (31.5-43.8%), and vancomycin rebound was 9.8% (2.5-13.7%). The vancomycin dose administered post-SLED was 1000 mg (875-1125 mg). For 18 patients, the patient-specific volume of distribution was 0.88 L/kg (0.67-1.1 L/kg), vancomycin clearance was 3.5 L/hr (2.2-5.2 L/hr), and the area under the concentration-time curve during the study time period was 280.8 mg·hr/L (254.7-297.3 mg·hr/L). CONCLUSION Vancomycin is significantly removed during SLED with little rebound in serum concentrations 4 hours after completion of SLED. Based on study findings, patients who are critically ill require additional vancomycin dosing after each SLED session to maintain therapeutic post-SLED vancomycin concentrations. Therapeutic drug monitoring of vancomycin is recommended during SLED.
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Affiliation(s)
- Taylor R Rider
- Department of Pharmacy, Rochester General Hospital, Rochester, New York, USA
| | - Kevin M Silinskie
- Department of Pharmacy, Rochester General Hospital, Rochester, New York, USA
| | - Mindee S Hite
- Department of Pharmacy, Rochester General Hospital, Rochester, New York, USA
| | - Jonathan Bress
- Nephrology Department, Rochester General Hospital, Rochester, New York, USA
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Vancomycin for Dialytic Therapy in Critically Ill Patients: Analysis of Its Reduction and the Factors Associated with Subtherapeutic Concentrations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17186861. [PMID: 32961829 PMCID: PMC7558948 DOI: 10.3390/ijerph17186861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022]
Abstract
This study aimed to evaluate the reduction in vancomycin through intermittent haemodialysis (IHD) and prolonged haemodialysis (PHD) in acute kidney injury (AKI) patients with sepsis and to identify the variables associated with subtherapeutic concentrations. A prospective study was performed in patients admitted at an intensive care unit (ICU) of a Brazilian hospital. Blood samples were collected at the start of dialytic therapy, after 2 and 4 h of treatment and at the end of therapy to determine the serum concentration of vancomycin and thus perform pharmacokinetic evaluation and PK/PD modelling. Twenty-seven patients treated with IHD, 17 treated with PHD for 6 h and 11 treated with PHD for 10 h were included. The reduction in serum concentrations of vancomycin after 2 h of therapy was 26.65 ± 12.64% and at the end of dialysis was 45.78 ± 12.79%, higher in the 10-h PHD group, 57.70% (40, 48–64, 30%) (p = 0.037). The ratio of the area under the curve to minimal inhibitory concentration (AUC/MIC) at 24 h in the PHD group was significantly smaller than at 10 h (p = 0.047). In the logistic regression, PHD was a risk factor for an AUC/MIC ratio less than 400 (OR = 11.59, p = 0.033), while a higher serum concentration of vancomycin at T0 was a protective factor (OR = 0.791, p = 0.009). In conclusion, subtherapeutic concentrations of vancomycin in acute kidney injury (AKI) patients in dialysis were elevated and may be related to a higher risk of bacterial resistance and mortality, besides pointing out the necessity of additional doses of vancomycin during dialytic therapy, mainly in PHD.
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10
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Parker SL, Abdul-Aziz MH, Roberts JA. The role of antibiotic pharmacokinetic studies performed post-licensing. Int J Antimicrob Agents 2020; 56:106165. [PMID: 32941948 DOI: 10.1016/j.ijantimicag.2020.106165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/29/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
Post-licensing pharmacometric studies can provide a better understanding of the pharmacokinetic (PK) alterations in special patient populations and may lead to better clinical outcomes. Some patient populations exhibit markedly different pathophysiology to general ward patients or healthy individuals. This may be developmental (paediatric patients), a manifestation of an underlying disease pathology (patients with obesity or haematological malignancies) or due to medical interventions (critically ill patients receiving extracorporeal therapies). This paper outlines the factors that affect the PK of special patient populations and describes some novel methods of antimicrobial administration that may increase antimicrobial concentrations at the site of infection and improve treatment of severe infection.
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Affiliation(s)
- Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
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11
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Lin SY, Shen LJ, Wu VC, Ko WJ, Wu CC, Wu FLL. Pharmacokinetics and dosing of vancomycin in patients undergoing sustained low efficiency daily diafiltration (SLEDD-f): A prospective study. J Formos Med Assoc 2020; 120:737-743. [PMID: 32855036 DOI: 10.1016/j.jfma.2020.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/22/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND/PURPOSE The pharmacokinetics of vancomycin in patients who undergo sustained low efficiency daily diafiltration (SLEDD-f) is not clear. This study aimed to determine the appropriate vancomycin dosage regimen for patients receiving SLEDD-f. METHODS This prospectively observational study enrolled critically ill patients older than 18 years old that used SLEDD-f as renal replacement therapy and received vancomycin treatment. An 8-h SLEDD-f was performed with FX-60 (high-flux helixone membrane, 1.4 m2). Serial blood samples were collected before, during, and after SLEDD-f to analyse vancomycin serum concentrations. Effluent fluid samples (a mixture of dialysate and ultrafiltrate) were also collected to determine the amount of vancomycin removal. RESULTS Seventeen patients were enrolled, and 10 completed the study. The amount of vancomycin removal was 447.4 ± 88.8 mg (about 78.4 ± 18.4% of the dose administered before SLEDD-f). The vancomycin concentration was reduced by 57.5 ± 14.9% during SLEDD-f, and this reduction was followed by a rebound with duration of one to three hours. The elimination half-life of vancomycin decreased from 64.1 ± 35.7 h before SLEDD-f to 7.0 ± 3.0 h during SLEDD-f. CONCLUSION Significant amount of vancomycin removed during SLEDD-f. Despite the existence of post-dialysis rebound, a sufficient supplemental dose is necessary to maintain therapeutic range.
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Affiliation(s)
- Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen S. Rd., Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen South Road, Taipei, Taiwan
| | - Li-Jiuan Shen
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen S. Rd., Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen South Road, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Wen-Je Ko
- Department of Traumatology, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Chien-Chih Wu
- Department of Pharmacy, National Taiwan University Hospital, No. 7, Zhongshan S. Rd., Taipei, Taiwan; Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen S. Rd., Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen South Road, Taipei, Taiwan
| | - Fe-Lin Lin Wu
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen S. Rd., Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, No. 33, Linsen South Road, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Cancer Centre, College of Medicine, National Taiwan University, No. 57, Ln. 155, Sec. 3, Keelung Rd., Taipei, Taiwan.
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12
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Lv M, Ma S, Chen N, Liu Y, Yu Z. Effective treatment of vancomycin nephrotoxicity with continuous venous-venous haemodiafiltration (CVVHDF) in a paediatric patient. J Clin Pharm Ther 2020; 45:852-855. [PMID: 32419173 DOI: 10.1111/jcpt.13181] [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] [Received: 11/05/2019] [Revised: 04/25/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Vancomycin removal by dialysis uses methods that differ in type of dialysis membrane, dialysis fluxes and duration, ultrafiltration rate and Kt/Vurea (K = dialyser urea clearance, t = time on dialysis and V = total body water) in case of nephrotoxicity. We applied continuous venous-venous haemodiafiltration (CVVHDF) to treat a paediatric case of vancomycin nephrotoxicity caused by high serum trough concentrations. CASE SUMMARY We report the case of a 4-year and 7-month-old boy with serum trough concentration of vancomycin of 86.0 mg/L after a 2-day treatment with vancomycin. His serum creatinine increased from 13.3 μmol/L at baseline to 227.0 μmol/L. We discontinued vancomycin and performed a 22-hours CVVHDF with high-flux membrane. Vancomycin decreased by 69.4% (82.1-25.1 mg/L), and renal function improved. WHAT IS NEW AND CONCLUSION Therapeutic drug monitoring and laboratory indicator measurements should be performed early during vancomycin treatment in paediatric patients with nephrotoxicity risk factors. Vancomycin removal by CVVHDF can be effective in paediatric acute kidney injury (AKI) associated with vancomycin-associated nephrotoxicity (VAN).
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Affiliation(s)
- Meng Lv
- Department of Pharmacy, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Shuli Ma
- Department of Pharmacy, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Nan Chen
- Department of Pharmacy, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yan Liu
- Department of Pharmacy, Henan Provincial Hospital, Zhengzhou, China
| | - Zutao Yu
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
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13
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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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Ponce D, Zamoner W, Freitas FM, Balbi A, Awdishu L. Vancomycin Removal During High-Volume Peritoneal Dialysis in Acute Kidney Injury Patients. ARCH ESP UROL 2019; 39:183-187. [PMID: 30858287 DOI: 10.3747/pdi.2018.00092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Studies on vancomycin pharmacokinetics in acute kidney injury (AKI) patients on high-volume peritoneal dialysis (HVPD) are lacking. We studied the pharmacokinetics of intravenous (IV) vancomycin in AKI patients treated by HVPD who received a prescribed single IV dose of vancomycin (15 - 20 mg/kg total body weight) to determine the extent of vancomycin removal and to establish vancomycin dosing guidelines for the empirical treatment of AKI patients receiving HVPD. The application of 18 mg/kg vancomycin every 48 - 72 hours in AKI patients undergoing HVPD was required to maintain therapeutic concentrations.
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Affiliation(s)
- Daniela Ponce
- São Paulo State University - UNESP, Botucatu, São Paulo, Brazil .,Bauru Course of Medicine - USP, Botucatu, São Paulo, Brazil
| | - Welder Zamoner
- São Paulo State University - UNESP, Botucatu, São Paulo, Brazil
| | | | - André Balbi
- São Paulo State University - UNESP, Botucatu, São Paulo, Brazil
| | - Linda Awdishu
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of San Diego, California, USA
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15
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Zamoner W, Prado IRS, Balbi AL, Ponce D. Vancomycin dosing, monitoring and toxicity: Critical review of the clinical practice. Clin Exp Pharmacol Physiol 2019; 46:292-301. [DOI: 10.1111/1440-1681.13066] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/03/2019] [Accepted: 01/04/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Welder Zamoner
- Botucatu School of Medicine University São Paulo State‐UNESP Botucatu Brazil
| | | | - André Luis Balbi
- Botucatu School of Medicine University São Paulo State‐UNESP Botucatu Brazil
| | - Daniela Ponce
- Botucatu School of Medicine University São Paulo State‐UNESP Botucatu Brazil
- Bauru School of Medicine – USPUniversity of São Paulo Bauru Brazil
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16
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Rodríguez N, Gómez M, Rico N, María Campistol J, Maduell F. Vancomycin hemodialysis: Clearance differences between high‐flux hemodialysis and on‐line hemodiafiltration. Artif Organs 2018; 43:261-269. [DOI: 10.1111/aor.13368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/03/2018] [Accepted: 10/02/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Néstor Rodríguez
- Nephrology and Renal Transplantation Department Hospital Clinic Barcelona Barcelona Spain
| | - Miquel Gómez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació Clínic per a la Recerca Biomèdica (FCRB) Hospital Clínic de Barcelona Barcelona Spain
| | - Naira Rico
- Nephrology and Renal Transplantation Department Hospital Clinic Barcelona Barcelona Spain
| | - Josep María Campistol
- Nephrology and Renal Transplantation Department Hospital Clinic Barcelona Barcelona Spain
| | - Francisco Maduell
- Nephrology and Renal Transplantation Department Hospital Clinic Barcelona Barcelona Spain
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Ponce D, Zamoner W, Freitas FM, Balbi A, Awdishu L. Vancomycin Removal During High-Volume Peritoneal Dialysis in Acute Kidney Injury Patients: A Prospective Cohort Clinical Study. Kidney Int Rep 2018; 4:112-118. [PMID: 30596174 PMCID: PMC6308823 DOI: 10.1016/j.ekir.2018.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/01/2018] [Accepted: 09/19/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction Vancomycin pharmacokinetic data in patients with acute kidney injury (AKI) on high-volume peritoneal dialysis (HVPD) are lacking. The aims were to study the pharmacokinetics of i.v. vancomycin in patients with AKI treated by HVPD who received an i.v. dose of vancomycin (15–20 mg/kg), to determine the vancomycin removal, and to establish vancomycin dosing and evaluation pharmacokinetics target attainment achievement for the empirical treatment of patients with AKI treated by HVPD. Methods Vancomycin was administered 1 hour before dialysis start. Samples of all dialysate were collected for a 24-hour period. Blood samples were collected after 1, 2, 4, and 24 hours of therapy. Vancomycin concentrations were determined using a liquid chromatographic (high-performance liquid chromatography)–fluorescence method. Pharmacokinetic calculations were completed assuming a 1-compartment model. Results Ten patients completed the study. The mean vancomycin dose administered was 18.0 ± 2.95 mg/kg (14.7–21.8 mg/kg) on the day of study (first day) and the mean percentage of vancomycin removal by HVPD was 21.7% ± 2.2% (16%–29%). Peritoneal clearance was 8.1 ± 2.2 ml/min (5.3–12 ml/min). The serum vancomycin half-life was 71.2 ± 24.7 hours (42–110 hours) during HVPD session, the maximum serum concentration was 26.2 ± 3.5 mg/l, which occurred 1 hour after vancomycin administration and HVPD start. Area under the curve (AUC)0–24/minimum inhibitory concentration (MIC) ratio ≥400 was achieved in all patients when MIC = 1 mg/l was considered. Conclusion HVPD removes considerable amounts of vancomycin in septic patients with AKI. Administration of 18 mg/kg vancomycin each 48 to 72 hours in patients with AKI undergoing HVPD was required to reach and maintain therapeutic concentrations.
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Affiliation(s)
- Daniela Ponce
- São Paulo State University-UNESP, Rubião Junior District, without number Botucatu, São Paulo, Brazil.,University of Sao Paulo-USP, Bauru School of Medicine, Bauru, Sao Paulo, Brazil
| | - Welder Zamoner
- São Paulo State University-UNESP, Rubião Junior District, without number Botucatu, São Paulo, Brazil
| | - Fernanda Moreira Freitas
- São Paulo State University-UNESP, Rubião Junior District, without number Botucatu, São Paulo, Brazil
| | - André Balbi
- São Paulo State University-UNESP, Rubião Junior District, without number Botucatu, São Paulo, Brazil
| | - Linda Awdishu
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of San Diego, California, USA
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18
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Un cas d’intoxication à la vancomycine traité avec succès par hémodialyse intermittente. Nephrol Ther 2018; 14:112-116. [DOI: 10.1016/j.nephro.2017.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 10/18/2017] [Accepted: 10/20/2017] [Indexed: 11/18/2022]
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19
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Economou CJP, Kielstein JT, Czock D, Xie J, Field J, Richards B, Tallott M, Visser A, Koenig C, Hafer C, Schmidt JJ, Lipman J, Roberts JA. Population pharmacokinetics of vancomycin in critically ill patients receiving prolonged intermittent renal replacement therapy. Int J Antimicrob Agents 2018. [PMID: 29526606 DOI: 10.1016/j.ijantimicag.2018.03.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The aim of this study was to describe the population pharmacokinetics of vancomycin during prolonged intermittent renal replacement therapy (PIRRT) in critically ill patients with acute kidney injury. METHODS Critically ill patients prescribed vancomycin across two sites had blood samples collected during one to three dosing intervals during which PIRRT was performed. Plasma samples were assayed with a validated immunoassay method. Population pharmacokinetic analysis and Monte Carlo simulations were performed using Pmetrics®. The target vancomycin exposures were the area under the concentration-time curve within a 24-h period (AUC0-24)/minimum inhibitory concentration (MIC) ratio of 400 for efficacy and AUC0-24 700 for toxicity. RESULTS Eleven critically ill patients (seven male) were enrolled and contributed 192 plasma samples. The patient's mean ± standard deviation (SD) age, weight and body mass index (BMI) were 57 ± 13 years, 98 ± 43 kg and 31 ± 9 kg/m2, respectively. A two-compartment linear model adequately described the data. The mean ± SD population pharmacokinetic parameter estimates were PIRRT clearance (CL) 3.47 ± 1.99 L/h, non-PIRRT CL 2.15 ± 2.07 L/h, volume of distribution of the central compartment (Vc) 41.85 ± 24.33 L, distribution rate constant from central to peripheral compartment 5.97 ± 7.93 per h and from peripheral to central compartment 5.29 ± 6.65 per h. Assuming a MIC of 1 mg/L, vancomycin doses of 25 mg/kg per day are suggested to be efficacious, whilst minimising toxic, exposures. CONCLUSIONS This is the first population pharmacokinetic study of vancomycin in patients receiving PIRRT and we observed large pharmacokinetic variability. Empirically, weight-based doses that are appropriate for the duration of PIRRT, should be selected and supplemented with therapeutic drug monitoring.
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Affiliation(s)
- Caleb J P Economou
- University of Queensland Centre for Clinical Research, Faculty of Medicine, Australia; ICON Cancer Foundation, Department of Research, Brisbane, Queensland, Australia
| | - Jan T Kielstein
- Medical Clinic V, Nephrology, Rheumatology and Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jiao Xie
- University of Queensland Centre for Clinical Research, Faculty of Medicine, Australia
| | - Jonathan Field
- Department of Intensive Care Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Brent Richards
- Department of Intensive Care Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Mandy Tallott
- Department of Intensive Care Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Adam Visser
- Department of Intensive Care Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Christina Koenig
- Department of Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany; Hospital Pharmacy, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Hafer
- Medical Clinic V, Nephrology, Rheumatology and Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Julius J Schmidt
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, Faculty of Medicine, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia.
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20
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Nyman HA, Agarwal A, Senekjian HO, Leypoldt JK, Cheung AK. Removal of vancomycin administered during dialysis by a high-flux dialyzer. Hemodial Int 2018; 22:383-387. [DOI: 10.1111/hdi.12637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/07/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Heather A. Nyman
- College of Pharmacy; University of Utah; Salt Lake City Utah USA
| | - Adhish Agarwal
- Division of Nephrology and Hypertension, School of Medicine; University of Utah; Salt Lake City Utah USA
| | - Harry O. Senekjian
- Division of Nephrology and Hypertension; University of Utah; Ogden Utah USA
| | | | - Alfred K. Cheung
- Division of Nephrology & Hypertension and Dialysis Program; University of Utah, Medical Service, Veterans Affairs Salt Lake City Healthcare System
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21
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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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22
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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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23
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Development of a prototype blood fractionation cartridge for plasma analysis by paper spray mass spectrometry. CLINICAL MASS SPECTROMETRY 2016. [DOI: 10.1016/j.clinms.2016.12.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Zamoner W, de Freitas FM, Garms DSS, de Oliveira MG, Balbi AL, Ponce D. Pharmacokinetics and pharmacodynamics of antibiotics in critically ill acute kidney injury patients. Pharmacol Res Perspect 2016; 4:e00280. [PMID: 28097012 PMCID: PMC5226291 DOI: 10.1002/prp2.280] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/18/2016] [Indexed: 11/08/2022] Open
Abstract
Sepsis is the most common cause of death in critically ill patients and is associated with multiorgan failure, including acute kidney injury (AKI). This situation can require acute renal support and increase mortality. Therefore, it is essential to administer antimicrobials in doses that achieve adequate serum levels, avoiding both overdosing and drug toxicity as well as underdosing and the risk of antibiotic resistance and higher mortality. Currently, there are no validated guidelines on antibiotic dose adjustments in septic patients with AKI. The current recommendations were extrapolated from studies conducted in noncritical patients with end‐stage chronic kidney disease receiving chronic renal replacement therapy. This study aimed to review and discuss the complexity of this issue, considering several factors related to drug metabolism, the characteristics of critically ill patients, the properties of antimicrobial drugs and dialysis methods.
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Affiliation(s)
- Welder Zamoner
- Nephrology University São Paulo State-UNESP Botucatu SP 18618-970 Brazil
| | | | - Durval S S Garms
- Nephrology University São Paulo State-UNESP Botucatu SP 18618-970 Brazil
| | | | - André L Balbi
- Nephrology University São Paulo State-UNESP Botucatu SP 18618-970 Brazil
| | - Daniela Ponce
- Nephrology University São Paulo State-UNESP Botucatu SP 18618-970 Brazil
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25
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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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Abstract
PURPOSE OF REVIEW Despite concerns regarding efficacy and tolerability, vancomycin continues to be the standard treatment for skin and soft tissue infections (SSTIs) when β-lactam antimicrobials cannot be used. This review sought to establish the role of both old and new alternatives to vancomycin. Methods for achieving optimization of vancomycin therapy are also explored. RECENT FINDINGS Several meta-analyses have demonstrated poorer clinical outcomes when the vancomycin minimum inhibitory concentration approaches the breakpoint of 2 μg/ml. Higher doses should be utilized to optimize pharmacokinetics and pharmacodynamics when higher volumes of distribution occur (e.g. sepsis). Newer agents with established noninferiority to vancomycin include the oxazolidinones linezolid and tedizolid, the lipopeptide daptomycin, the anti-meticillin-resistant Staphylococcus aureus cephalosporin ceftaroline and the glycylcycline tigecycline. Linezolid is thus far the only agent that has been shown to be associated with better clinical and microbiological cure rates. Ceftaroline and tigecycline are broad-spectrum agents best reserved for polymicrobial infections (e.g. diabetic foot infections). SUMMARY When vancomycin is used for the treatment of SSTIs, maximizing the dose should be performed to improve efficacy. Cost is often the main limiting factor with regard to the newer agents, but their suitability for outpatient antimicrobial therapy may counteract this.
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The Impact of Variation in Renal Replacement Therapy Settings on Piperacillin, Meropenem, and Vancomycin Drug Clearance in the Critically Ill. Crit Care Med 2014; 42:1640-50. [DOI: 10.1097/ccm.0000000000000317] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Petejova N, Martinek A, Zahalkova J, Duricova J, Brozmannova H, Urbanek K, Grundmann M, Plasek J, Kacirova I. Vancomycin pharmacokinetics during high-volume continuous venovenous hemofiltration in critically ill septic patients. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:65-72. [DOI: 10.5507/bp.2012.092] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Indexed: 11/23/2022] Open
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