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Novy E, Abdul-Aziz MH, Cheng V, Burrows F, Buscher H, Corley A, Diehl A, Gilder E, Levkovich BJ, McGuinness S, Ordonez J, Parke R, Parker S, Pellegrino V, Reynolds C, Rudham S, Wallis SC, Welch SA, Fraser JF, Shekar K, Roberts JA. Population pharmacokinetics of fluconazole in critically ill patients receiving extracorporeal membrane oxygenation and continuous renal replacement therapy: an ASAP ECMO study. Antimicrob Agents Chemother 2024; 68:e0120123. [PMID: 38063399 PMCID: PMC10777822 DOI: 10.1128/aac.01201-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
This multicenter study describes the population pharmacokinetics (PK) of fluconazole in critically ill patients receiving concomitant extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) and includes an evaluation of different fluconazole dosing regimens for achievement of target exposure associated with maximal efficacy. Serial blood samples were obtained from critically ill patients on ECMO and CRRT receiving fluconazole. Total fluconazole concentrations were measured in plasma using a validated chromatographic assay. A population PK model was developed and Monte Carlo dosing simulations were performed using Pmetrics in R. The probability of target attainment (PTA) of various dosing regimens to achieve fluconazole area under the curve to minimal inhibitory concentration ratio (AUC0-24/MIC) >100 was estimated. Eight critically ill patients receiving concomitant ECMO and CRRT were included. A two-compartment model including total body weight as a covariate on clearance adequately described the data. The mean (±standard deviation, SD) clearance and volume of distribution were 2.87 ± 0.63 L/h and 15.90 ± 13.29 L, respectively. Dosing simulations showed that current guidelines (initial loading dose of 12 mg/kg then 6 mg/kg q24h) achieved >90% of PTA for a MIC up to 1 mg/L. None of the tested dosing regimens achieved 90% of PTA for MIC above 2 mg/L. Current fluconazole dosing regimen guidelines achieved >90% PTA only for Candida species with MIC <1 mg/L and thus should be only used for Candida-documented infections in critically ill patients receiving concomitant ECMO and CRRT. Total body weight should be considered for fluconazole dose.
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Affiliation(s)
- Emmanuel Novy
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
- Université de Lorraine, SIMPA, Nancy, France
- Departement of anesthesiology, Critical care and peri-operative medicine, University hospital of Nancy, Nancy, France
| | - Mohd H. Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Vesa Cheng
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Fay Burrows
- Department of Pharmacy, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
- University of New South Wales, St Vincent’s Centre for Applied Medical Research, Sydney, New South Wales, Australia
| | - Amanda Corley
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eileen Gilder
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Bianca J. Levkovich
- Experiential Development and Graduate Education and Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shay McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Jenny Ordonez
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The University of Auckland, School of Nursing, Auckland, New Zealand
| | - Suzanne Parker
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Claire Reynolds
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Sam Rudham
- Department of Intensive Care Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Steven C. Wallis
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Susan A. Welch
- Department of Pharmacy, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - John F. Fraser
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kiran Shekar
- The Prince Charles Hospital, Critical Care Research Group and Adult Intensive Care Services, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jason A. Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Williams P, Cotta MO, Abdul-Aziz MH, Wilks K, Farkas A, Roberts JA. In silico Evaluation of a Vancomycin Dosing Guideline Among Adults with Serious Infections. Ther Drug Monit 2023; 45:631-636. [PMID: 37199397 DOI: 10.1097/ftd.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND This study aimed to compare the achievement of pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for vancomycin using a newly developed dosing guideline with product-information-based dosing in the treatment of adult patients with serious infections. METHODS In silico product-information- and guideline-based dosing simulations for vancomycin were performed across a range of doses and patient characteristics, including body weight, age, and renal function at 36-48 and 96 hours, using a pharmacokinetic model derived from a seriously ill patient population. The median simulated concentration and area under the 24-hour concentration-time curve (AUC 0-24 ) were used to measure predefined therapeutic, subtherapeutic, and toxicity PK-PD targets. RESULTS Ninety-six dosing simulations were performed. The pooled median trough concentration target with guideline-based dosing at 36 and 96 hours was achieved in 27.1% (13/48) and 8.3% (7/48) of simulations, respectively. The pooled median AUC 0-24 /minimum inhibitory concentration ratio with guideline-based dosing at 48 and 96 hours was attained in 39.6% (19/48) and 27.1% (13/48) of simulations, respectively. Guideline-based dosing simulations yielded improved trough target attainment compared with product-information-based dosing at 36 hours and significantly less subtherapeutic drug exposure. The toxicity threshold was exceeded in 52.1% (25/48) and 0% (0/48) for guideline- and product-information-information-based dosing, respectively ( P < 0.001). CONCLUSIONS A Critical care vancomycin dosing guideline appeared slightly more effective than standard dosing, as per product information, in achieving PK-PD exposure associated with an increased likelihood of effectiveness. In addition, this guideline significantly reduced the risk of subtherapeutic exposure. The risk of exceeding toxicity thresholds, however, was greater with the guideline, and further investigation is suggested to improve dosing accuracy and sensitivity.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West, New York, New York
- Optimum Dosing Strategies, Bloomingdale, New Jersey
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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Shekar K, Abdul-Aziz MH, Cheng V, Burrows F, Buscher H, Cho YJ, Corley A, Diehl A, Gilder E, Jakob SM, Kim HS, Levkovich BJ, Lim SY, McGuinness S, Parke R, Pellegrino V, Que YA, Reynolds C, Rudham S, Wallis SC, Welch SA, Zacharias D, Fraser JF, Roberts JA. Antimicrobial Exposures in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med 2023; 207:704-720. [PMID: 36215036 DOI: 10.1164/rccm.202207-1393oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Data suggest that altered antimicrobial concentrations are likely during extracorporeal membrane oxygenation (ECMO). Objectives: The primary aim of this analysis was to describe the pharmacokinetics (PKs) of antimicrobials in critically ill adult patients receiving ECMO. Our secondary aim was to determine whether current antimicrobial dosing regimens achieve effective and safe exposure. Methods: This study was a prospective, open-labeled, PK study in six ICUs in Australia, New Zealand, South Korea, and Switzerland. Serial blood samples were collected over a single dosing interval during ECMO for 11 antimicrobials. PK parameters were estimated using noncompartmental methods. Adequacy of antimicrobial dosing regimens were evaluated using predefined concentration exposures associated with maximal clinical outcomes and minimal toxicity risks. Measurements and Main Results: We included 993 blood samples from 85 patients. The mean age was 44.7 ± 14.4 years, and 61.2% were male. Thirty-eight patients (44.7%) were receiving renal replacement therapy during the first PK sampling. Large variations (coefficient of variation of ⩾30%) in antimicrobial concentrations were seen leading to more than fivefold variations in all PK parameters across all study antimicrobials. Overall, 70 (56.5%) concentration profiles achieved the predefined target concentration and exposure range. Target attainment rates were not significantly different between modes of ECMO and renal replacement therapy. Poor target attainment was observed across the most frequently used antimicrobials for ECMO recipients, including for oseltamivir (33.3%), piperacillin (44.4%), and vancomycin (27.3%). Conclusions: Antimicrobial PKs were highly variable in critically ill patients receiving ECMO, leading to poor target attainment rates. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000559819).
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Affiliation(s)
- Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Vesa Cheng
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
- St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Amanda Corley
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine and
| | - Eileen Gilder
- Experiential Development and Graduate Education and Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Stephan M Jakob
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Hyung-Sook Kim
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bianca J Levkovich
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Shay McGuinness
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Rachael Parke
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine and
| | - Yok-Ai Que
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Claire Reynolds
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sam Rudham
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | | | - David Zacharias
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - John F Fraser
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Abdul-Aziz MH, Roberts JA, Shekar K. Reply to Fillatre, et al. and Li, et al. Am J Respir Crit Care Med 2022; 207:952-953. [PMID: 36473254 PMCID: PMC10111980 DOI: 10.1164/rccm.202211-2140le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Jason A Roberts
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Kiran Shekar
- University of Queensland, Medicine, Brisbane, Queensland, Australia
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Cheng V, Abdul-Aziz MH, Burrows F, Buscher H, Corley A, Diehl A, Levkovich BJ, Pellegrino V, Reynolds C, Rudham S, Wallis SC, Welch SA, Roberts JA, Shekar K, Fraser JF. Population pharmacokinetics of ciprofloxacin in critically ill patients receiving extracorporeal membrane oxygenation (an ASAP ECMO study). Anaesth Crit Care Pain Med 2022; 41:101080. [PMID: 35472580 DOI: 10.1016/j.accpm.2022.101080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION This study aimed to describe the pharmacokinetics (PK) of ciprofloxacin in critically ill patients receiving ECMO and recommend a dosing regimen that provides adequate drug exposure. METHODS Serial blood samples were taken from ECMO patients receiving ciprofloxacin. Total ciprofloxacin concentrations were measured by chromatographic assay and analysed using a population PK approach with Pmetrics®. Dosing simulations were performed to ascertain the probability of target attainment (PTA) represented by the area under the curve to minimum inhibitory concentration ratio (AUC0-24/MIC) ≥ 125. RESULTS Eight patients were enrolled, of which three received concurrent continuous venovenous haemodiafiltration (CVVHDF). Ciprofloxacin was best described in a two-compartment model with total body weight and creatinine clearance (CrCL) included as significant predictors of PK. Patients not requiring renal replacement therapy generated a mean clearance of 11.08 L/h while patients receiving CVVHDF had a mean clearance of 1.51 L/h. Central and peripheral volume of distribution was 77.31 L and 90.71 L, respectively. ECMO variables were not found to be significant predictors of ciprofloxacin PK. Dosing simulations reported that a 400 mg 8 -hly regimen achieved > 72% PTA in all simulated patients with CrCL of 30 mL/min, 50 mL/min and 100 mL/min and total body weights of 60 kg and 100 kg at a MIC of 0.5 mg/L. CONCLUSION Our study reports that established dosing recommendations for critically ill patients not on ECMO provides sufficient drug exposure for maximal ciprofloxacin activity for ECMO patients. In line with non-ECMO critically ill adult PK studies, higher doses and therapeutic drug monitoring may be required for critically ill adult patients on ECMO.
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Affiliation(s)
- Vesa Cheng
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Fay Burrows
- Department of Pharmacy, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia; St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Amanda Corley
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bianca J Levkovich
- Experiential Development and Graduate Education and Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Vincent Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Claire Reynolds
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sam Rudham
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Susan A Welch
- Department of Pharmacy, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - John F Fraser
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia; Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
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Giacobbe DR, Roberts JA, Abdul-Aziz MH, de Montmollin E, Timsit JF, Bassetti M. Treatment of ventilator-associated pneumonia due to carbapenem-resistant Gram-negative bacteria with novel agents: a contemporary, multidisciplinary ESGCIP perspective. Expert Rev Anti Infect Ther 2022; 20:963-979. [PMID: 35385681 DOI: 10.1080/14787210.2022.2063838] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION : In the past 15 years, treatment of VAP caused by carbapenem-resistant Gram-negative bacteria (CR-GNB) has represented an intricate challenge for clinicians. AREAS COVERED In this perspective article, we discuss the available clinical data about novel agents for the treatment of CR-GNB VAP, together with general PK/PD principles for the treatment of VAP, in the attempt to provide some suggestions for optimizing antimicrobial therapy of CR-GNB VAP in the daily clinical practice. EXPERT OPINION Recently, novel BL and BL/BLI combinations have become available that have shown potent in vitro activity against CR-GNB and have attracted much interest as novel, less toxic, and possibly more efficacious options for the treatment of CR-GNB VAP compared with previous standard of care. Besides randomized controlled trials, a good solution to enrich our knowledge on how to use these novel agents at best in the near future, while at the same time remaining adherent to current evidence-based guidelines, is to improve our collaboration to conduct larger multinational observational studies to collect sufficiently large populations treated in real life with those novel agents for which guidelines currently do not provide a recommendation (in favor or against) for certain causative organisms.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
| | - Jason A Roberts
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Herston Infectious Diseases Institute (HeIDI), Metro North Health, 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
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Etienne de Montmollin
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Jean-François Timsit
- Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID).,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat Claude Bernard University Hospital, Paris, France.,INSERM IAME UMR 1137, University of Paris, Sorbonne Paris Cite, Paris, France
| | - Matteo Bassetti
- Infectious Diseases Unit, San Martino Policlinico Hospital - IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Critically ill patients study group (ESGCIP) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID)
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Sulaiman H, Roberts JA, Abdul-Aziz MH. Pharmacokinetics and pharmacodynamics of beta-lactam antibiotics in critically ill patients. Farm Hosp 2022; 46:182-190. [PMID: 36183212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Abstract
Optimal antibiotic therapy for critically ill patients can be complicated bythe altered physiology associated with critical illness. Antibiotic pharmacokineticsand exposures can be altered driven by the underlying critical illnessand medical interventions that critically ill patients receive in the intensivecare unit. Furthermore, pathogens that are usually isolated in the intensivecare unit are commonly less susceptible and "resistant" to common antibiotics.Indeed, antibiotic dosing that does not consider these unique differenceswill likely fail leading to poor clinical outcomes and the emergenceof antibiotic resistance in the intensive care unit. The aims of this narrativereview were to describe the pharmacokinetics of beta-lactam antibiotics incritically ill patients, to highlight pharmacokinetic/pharmacodynamic targetsfor both non-critically ill and critically ill patients, and to discuss importantstrategies that can be undertaken to optimize beta-lactam antibiotic dosingfor critically ill patients in the intensive care unit.
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Affiliation(s)
- Helmi Sulaiman
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia..
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia. Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia. Department of Pharmacy, 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..
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia..
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Abdul-Aziz MH, Brady K, Cotta MO, Roberts JA. Therapeutic Drug Monitoring of Antibiotics: Defining the Therapeutic Range. Ther Drug Monit 2022; 44:19-31. [PMID: 34750338 DOI: 10.1097/ftd.0000000000000940] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In the present narrative review, the authors aimed to discuss the relationship between the pharmacokinetic/pharmacodynamic (PK/PD) of antibiotics and clinical response (including efficacy and toxicity). In addition, this review describes how this relationship can be applied to define the therapeutic range of a particular antibiotic (or antibiotic class) for therapeutic drug monitoring (TDM). METHODS Relevant clinical studies that examined the relationship between PK/PD of antibiotics and clinical response (efficacy and response) were reviewed. The review (performed for studies published in English up to September 2021) assessed only commonly used antibiotics (or antibiotic classes), including aminoglycosides, beta-lactam antibiotics, daptomycin, fluoroquinolones, glycopeptides (teicoplanin and vancomycin), and linezolid. The best currently available evidence was used to define the therapeutic range for these antibiotics. RESULTS The therapeutic range associated with maximal clinical efficacy and minimal toxicity is available for commonly used antibiotics, and these values can be implemented when TDM for antibiotics is performed. Additional data are needed to clarify the relationship between PK/PD indices and the development of antibiotic resistance. CONCLUSIONS TDM should only be regarded as a means to achieve the main goal of providing safe and effective antibiotic therapy for all patients. The next critical step is to define exposures that can prevent the development of antibiotic resistance and include these exposures as therapeutic drug monitoring targets.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Kara Brady
- Adult Intensive Care Unit and Pharmacy, The Prince Charles Hospital, Brisbane, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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9
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Roberts JA, Bellomo R, Cotta MO, Koch BCP, Lyster H, Ostermann M, Roger C, Shekar K, Watt K, Abdul-Aziz MH. Machines that help machines to help patients: optimising antimicrobial dosing in patients receiving extracorporeal membrane oxygenation and renal replacement therapy using dosing software. Intensive Care Med 2022; 48:1338-1351. [PMID: 35997793 PMCID: PMC9467945 DOI: 10.1007/s00134-022-06847-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/29/2022] [Indexed: 02/04/2023]
Abstract
Intensive care unit (ICU) patients with end-organ failure will require specialised machines or extracorporeal therapies to support the failing organs that would otherwise lead to death. ICU patients with severe acute kidney injury may require renal replacement therapy (RRT) to remove fluid and wastes from the body, and patients with severe cardiorespiratory failure will require extracorporeal membrane oxygenation (ECMO) to maintain adequate oxygen delivery whilst the underlying pathology is evaluated and managed. The presence of ECMO and RRT machines can further augment the existing pharmacokinetic (PK) alterations during critical illness. Significant changes in the apparent volume of distribution (Vd) and drug clearance (CL) for many important drugs have been reported during ECMO and RRT. Conventional antimicrobial dosing regimens rarely consider the impact of these changes and consequently, are unlikely to achieve effective antimicrobial exposures in critically ill patients receiving ECMO and/or RRT. Therefore, an in-depth understanding on potential PK changes during ECMO and/or RRT is required to inform antimicrobial dosing strategies in patients receiving ECMO and/or RRT. In this narrative review, we aim to discuss the potential impact of ECMO and RRT on the PK of antimicrobials and antimicrobial dosing requirements whilst receiving these extracorporeal therapies. The potential benefits of therapeutic drug monitoring (TDM) and dosing software to facilitate antimicrobial therapy for critically ill patients receiving ECMO and/or RRT are also reviewed and highlighted.
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Affiliation(s)
- Jason A. Roberts
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia ,Herston Infectious Diseases (HeIDI), Metro North Health, Brisbane, QLD Australia ,grid.416100.20000 0001 0688 4634Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, QLD Australia ,grid.121334.60000 0001 2097 0141Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Rinaldo Bellomo
- grid.1008.90000 0001 2179 088XDepartment of Critical Care, The University of Melbourne, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia ,grid.414094.c0000 0001 0162 7225Department of Intensive Care, Austin Hospital, Melbourne, Australia ,grid.416153.40000 0004 0624 1200Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Menino O. Cotta
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia
| | - Birgit C. P. Koch
- grid.5645.2000000040459992XDepartment of Hospital Pharmacy, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Haifa Lyster
- Pharmacy Department, Royal Brompton and Harefield Hospitals, London, SW3 6NP UK ,Cardiothoracic Transplant Unit, Royal Brompton and Harefield Hospitals, London, SW3 6NP UK
| | - Marlies Ostermann
- grid.425213.3Department of Critical Care, King’s College London, Guy’s and St Thomas Hospital, London, SE1 7EH UK
| | - Claire Roger
- Department of Anaesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, 30 029 Nîmes cedex 9, France ,grid.121334.60000 0001 2097 0141UR UM 103 IMAGINE, Faculty of Medicine, University of Montpellier, Nîmes, France
| | - Kiran Shekar
- grid.415184.d0000 0004 0614 0266Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD Australia ,grid.1003.20000 0000 9320 7537Faculty of Medicine, The University of Queensland, Brisbane, QLD Australia ,grid.1024.70000000089150953Faculty of Health, Queensland University of Technology, Brisbane, QLD Australia ,grid.1033.10000 0004 0405 3820Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD Australia
| | - Kevin Watt
- grid.46078.3d0000 0000 8644 1405School of Pharmacy, University of Waterloo, 10 Victoria St S. Kitchener, Waterloo, ON N2G 1C5 Canada ,grid.223827.e0000 0001 2193 0096Department of Paediatrics, University of Utah School of Medicine, Salt Lake City, UT USA
| | - Mohd H. Abdul-Aziz
- grid.1003.20000 0000 9320 7537Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD 4029 Australia
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10
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Cheng V, Abdul-Aziz MH, Roberts JA. Applying Antimicrobial Pharmacokinetic Principles for Complex Patients: Critically Ill Adult Patients Receiving Extracorporeal Membrane Oxygenation and Renal Replacement Therapy. Curr Infect Dis Rep 2021. [DOI: 10.1007/s11908-021-00757-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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11
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Dhanani J, Pang G, Pincus J, Ahern B, Goodwin W, Cowling N, Whitten G, Abdul-Aziz MH, Martin S, Corke P, Laupland KB. Increasing ventilator surge capacity in COVID 19 pandemic: design, manufacture and in vitro-in vivo testing in anaesthetized healthy pigs of a rapid prototyped mechanical ventilator. BMC Res Notes 2020; 13:421. [PMID: 32894167 PMCID: PMC7475714 DOI: 10.1186/s13104-020-05259-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/27/2020] [Indexed: 12/16/2022] Open
Abstract
Objective The advent of new technologies has made it possible to explore alternative ventilator manufacturing to meet the worldwide shortfall for mechanical ventilators especially in pandemics. We describe a method using rapid prototyping technologies to create an electro-mechanical ventilator in a cost effective, timely manner and provide results of testing using an in vitro–in vivo testing model. Results Rapid prototyping technologies (3D printing and 2D cutting) were used to create a modular ventilator. The artificial manual breathing unit (AMBU) bag connected to wall oxygen source using a flow meter was used as air reservoir. Controlled variables include respiratory rate, tidal volume and inspiratory: expiratory (I:E) ratio. In vitro testing and In vivo testing in the pig model demonstrated comparable mechanical efficiency of the test ventilator to that of standard ventilator but showed the material limits of 3D printed gears. Improved gear design resulted in better ventilator durability whilst reducing manufacturing time (< 2-h). The entire cost of manufacture of ventilator was estimated at 300 Australian dollars. A cost-effective novel rapid prototyped ventilator for use in patients with respiratory failure was developed in < 2-h and was effective in anesthetized, healthy pig model.
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Affiliation(s)
- Jayesh Dhanani
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,University of Queensland Centre of Clinical Research, Faculty of Medicine, Level 8, The University of Queensland, Herston, QLD, 4029, Australia.
| | - George Pang
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Gatton, Australia
| | - Jason Pincus
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Gatton, Australia
| | - Benjamin Ahern
- School of Veterinary Science, Faculty of Science, University of Queensland, Gatton, Australia
| | - Wendy Goodwin
- School of Veterinary Science, Faculty of Science, University of Queensland, Gatton, Australia
| | - Nicholas Cowling
- School of Veterinary Science, Faculty of Science, University of Queensland, Gatton, Australia
| | - Grant Whitten
- School of Veterinary Science, Faculty of Science, University of Queensland, Gatton, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre of Clinical Research, Faculty of Medicine, Level 8, The University of Queensland, Herston, QLD, 4029, Australia
| | - Steven Martin
- Australian Centre for Robotic Vision, Queensland University of Technology, Brisbane, Australia
| | - Peter Corke
- Australian Centre for Robotic Vision, Queensland University of Technology, Brisbane, Australia
| | - Kevin B Laupland
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
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12
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Ranganathan D, Abdul-Aziz MH, John GT, McWhinney BC, Fassett RG, Healy H, Kubler P, Lim A, Lipman J, Purvey M, Roberts M, Reyaldeen R, Ungerer J, Roberts JA. Pharmacokinetics of Enteric-Coated Mycophenolate Sodium in Lupus Nephritis (POEMSLUN). Ther Drug Monit 2020; 41:703-713. [PMID: 31219949 PMCID: PMC6867677 DOI: 10.1097/ftd.0000000000000658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mycophenolate mofetil or enteric-coated mycophenolate sodium (EC-MPS) and steroids are used for induction and maintenance therapy in severe lupus nephritis. Blood concentrations of mycophenolic acid (MPA), the active metabolite of these drugs, vary among patients with lupus nephritis. The objective of this study was to examine whether concentration-controlled (CC) dosing (through therapeutic drug monitoring) of EC-MPS results in a higher proportion of participants achieving target exposure of MPA compared with fixed-dosing (FD). An additional aim of the study was to evaluate the influence of CC dosing on clinical outcomes. METHODS Nineteen participants were randomly assigned either to the FD or CC group. All the participants were eligible to have free and total measurements of MPA over a period of 8-12 hours on 3 different occasions. Area under the concentration-time curve between 0 and 12 hours (AUC0-12) was calculated using noncompartmental methods. Dose of EC-MPS was titrated according to AUC0-12 in the CC group. RESULTS Thirty-two AUC0-12 measurements were obtained from 9 FD and 9 CC participants. Large inter-patient variability was observed in both groups but was more pronounced in the FD group. There were no significant differences between FD and CC participants in any pharmacokinetic parameters across the study visits, except for total C0 (FD 2.0 ± 0.3 mg/L versus CC 1.1 ± 0.3; P = 0.01) and dose-normalized C0 (FD 2.9 ± 0.2 mg/L/g versus CC 2.1 ± 0.7 mg/L/g; P = 0.04) at the second visit and total AUC0-12 (FD 66.6 ± 6.0 mg·h/L versus CC 35.2 ± 11.4 mg·h/L; P = 0.03) at the third visit. At the first study visit, 33.3% of the FD and 11.1% of the CC participants achieved the target area under the concentration-time curve (P = 0.58). From the second visit, none of the FD participants, compared with all the CC participants, achieved target AUC0-12 (P = 0.01). More CC participants achieved remission compared with FD participants (absolute difference of -22.2, 95% confidence interval (Equation is included in full-text article.)0.19 to 0.55; P = 0.62). The mean free MPA AUC0-12 was significantly lower in those who had complete remission. CONCLUSIONS CC participants reached target AUC0-12 quicker. Larger studies are required to test clinical efficacy.
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Affiliation(s)
- Dwarakanathan Ranganathan
- Department of Renal Medicine, Royal Brisbane and Women's Hospital.,School of Medicine, Griffith University
| | - Mohd H Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland
| | - George T John
- Department of Renal Medicine, Royal Brisbane and Women's Hospital
| | | | - Robert G Fassett
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland
| | - Helen Healy
- Department of Renal Medicine, Royal Brisbane and Women's Hospital.,Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland
| | | | - Aaron Lim
- Department of Renal Medicine, Royal Brisbane and Women's Hospital
| | - Jeffrey Lipman
- Intensive Care Medicine, Royal Brisbane and Women's Hospital
| | - Megan Purvey
- Department of Renal Medicine, Royal Brisbane and Women's Hospital
| | - Matthew Roberts
- Department of Renal Medicine, Royal Brisbane and Women's Hospital
| | - Reza Reyaldeen
- Department of Renal Medicine, Royal Brisbane and Women's Hospital
| | | | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland.,Intensive Care Medicine, Royal Brisbane and Women's Hospital.,Pharmacy Department, Royal Brisbane and Women's Hospital.,Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Queensland, Australia
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Chai MG, Cotta MO, Abdul-Aziz MH, Roberts JA. What Are the Current Approaches to Optimising Antimicrobial Dosing in the Intensive Care Unit? Pharmaceutics 2020; 12:pharmaceutics12070638. [PMID: 32645953 PMCID: PMC7407796 DOI: 10.3390/pharmaceutics12070638] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial dosing in the intensive care unit (ICU) can be problematic due to various challenges including unique physiological changes observed in critically ill patients and the presence of pathogens with reduced susceptibility. These challenges result in reduced likelihood of standard antimicrobial dosing regimens achieving target exposures associated with optimal patient outcomes. Therefore, the aim of this review is to explore the various methods for optimisation of antimicrobial dosing in ICU patients. Dosing nomograms developed from pharmacokinetic/statistical models and therapeutic drug monitoring are commonly used. However, recent advances in mathematical and statistical modelling have resulted in the development of novel dosing software that utilise Bayesian forecasting and/or artificial intelligence. These programs utilise therapeutic drug monitoring results to further personalise antimicrobial therapy based on each patient’s clinical characteristics. Studies quantifying the clinical and cost benefits associated with dosing software are required before widespread use as a point-of-care system can be justified.
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Affiliation(s)
- Ming G. Chai
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
| | - Menino O. Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
| | - Mohd H. Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
| | - Jason A. Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia; (M.G.C.); (M.O.C.); (M.H.A.-A.)
- Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Woollongabba 4102, Australia
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women’s Hospital, Brisbane 4006, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, University of Montpellier, 30021 Nimes, France
- Correspondence:
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14
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Dhanani JA, Lipman J, Pincus J, Townsend S, Livermore A, Wallis SC, Pandey S, Abdul-Aziz MH, Roberts JA. Pharmacokinetics of Sulfamethoxazole and Trimethoprim During Venovenous Extracorporeal Membrane Oxygenation: A Case Report. Pharmacotherapy 2020; 40:713-717. [PMID: 32378219 DOI: 10.1002/phar.2413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) therapy could affect drug concentrations via adsorption onto the oxygenator and/or associated circuit. We describe a case of a 33-year-old man with severe respiratory failure due to Pneumocystis jirovecii infection on a background of recently diagnosed human immunodeficiency virus infection. He required venovenous ECMO therapy for refractory respiratory failure. Intravenous sulfamethoxazole-trimethoprim (100 and 20 mg/kg/day) was administered in a dosing regimen every 6 hours. Pre-oxygenator, post-oxygenator, and arterial blood samples were collected after antibiotic administration and were analyzed for total sulfamethoxazole and trimethoprim concentrations. The peak sulfamethoxazole and trimethoprim concentrations were 122 mg/L and 5.3 mg/L, respectively. The volume of distribution for sulfamethoxazole was 0.37 and 2.30 L/kg for trimethoprim. The clearance for sulfamethoxazole was 0.35 ml/minute/kg and for trimethoprim was 1.64 ml/minute/kg. The pharmacokinetics of sulfamethoxazole and trimethoprim appear not to be affected by ECMO therapy, and dosing adjustment may not be required.
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Affiliation(s)
- Jayesh A Dhanani
- Faculty of Medicine, University of Queensland Centre of Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jeffrey Lipman
- Faculty of Medicine, University of Queensland Centre of Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jason Pincus
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Shane Townsend
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Amelia Livermore
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven C Wallis
- Faculty of Medicine, University of Queensland Centre of Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Saurabh Pandey
- University Of Queensland Centre for Clinical Research, University of Queensland, Herston, Queensland, Australia
| | - Mohd H Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre of Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre of Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, 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.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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15
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Abdul-Aziz MH, Alffenaar JWC, Bassetti M, Bracht H, Dimopoulos G, Marriott D, Neely MN, Paiva JA, Pea F, Sjovall F, Timsit JF, Udy AA, Wicha SG, Zeitlinger M, De Waele JJ, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper .. Intensive Care Med 2020; 46:1127-1153. [PMID: 32383061 PMCID: PMC7223855 DOI: 10.1007/s00134-020-06050-1] [Citation(s) in RCA: 450] [Impact Index Per Article: 112.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Purpose This Position Paper aims to review and discuss the available data on therapeutic drug monitoring (TDM) of antibacterials, antifungals and antivirals in critically ill adult patients in the intensive care unit (ICU). This Position Paper also provides a practical guide on how TDM can be applied in routine clinical practice to improve therapeutic outcomes in critically ill adult patients.
Methods Literature review and analysis were performed by Panel Members nominated by the endorsing organisations, European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) and International Society of Antimicrobial Chemotherapy (ISAC). Panel members made recommendations for whether TDM should be applied clinically for different antimicrobials/classes. Results TDM-guided dosing has been shown to be clinically beneficial for aminoglycosides, voriconazole and ribavirin. For most common antibiotics and antifungals in the ICU, a clear therapeutic range has been established, and for these agents, routine TDM in critically ill patients appears meritorious. For the antivirals, research is needed to identify therapeutic targets and determine whether antiviral TDM is indeed meritorious in this patient population. The Panel Members recommend routine TDM to be performed for aminoglycosides, beta-lactam antibiotics, linezolid, teicoplanin, vancomycin and voriconazole in critically ill patients. Conclusion Although TDM should be the standard of care for most antimicrobials in every ICU, important barriers need to be addressed before routine TDM can be widely employed worldwide. Electronic supplementary material The online version of this article (10.1007/s00134-020-06050-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Hendrik Bracht
- Department of Anaesthesiology, University Ulm, Ulm, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Deborah Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael N Neely
- Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jose-Artur Paiva
- Department of Medicine, Faculty of Medicine of Porto, Porto, Portugal.,Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitario de São João, Porto, Portugal
| | - Federico Pea
- Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, Udine, Italy
| | - Fredrik Sjovall
- Department of Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
| | - Jean F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), Paris Diderot University, Paris, France
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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16
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Dhanani JA, Lipman J, Pincus J, Townsend S, Livermore A, Wallis SC, Abdul-Aziz MH, Roberts JA. Pharmacokinetics of Total and Unbound Cefazolin during Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report. Chemotherapy 2019; 64:115-118. [PMID: 31610538 DOI: 10.1159/000502474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/02/2019] [Indexed: 11/19/2022]
Abstract
Extra-corporeal membrane oxygenation (ECMO) therapy could affect effective drug concentrations via adsorption onto the oxygenator or associated circuit. We describe a case of a 25-year-old female who required a veno-arterial ECMO therapy for refractory cardiac arrest due to massive pulmonary embolism. She had mild renal dysfunction as a result of the cardiac arrest. A total of 2 g of intravenous cefazolin 8-hourly was administered. Pre- and post-oxygenator blood samples were collected at 0, 1, 4, and 8 h post antibiotic administration. Samples were analyzed for total and unbound cefazolin concentrations. Protein binding was ∼60%. Clearance was reduced due to impaired renal function. The pharmacokinetics of cefazolin appear to not be affected by ECMO therapy and dosing adjustment may not be required.
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Affiliation(s)
- Jayesh A Dhanani
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia, .,Queensland University of Technology, School of Nursing, Herston, Queensland, Australia, .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia,
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Jason Pincus
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Shane Townsend
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Amelia Livermore
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven C Wallis
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, 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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17
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Abdul-Aziz MH, Shekar K, Roberts JA. Antimicrobial therapy during ECMO - customised dosing with therapeutic drug monitoring: The way to go? Anaesth Crit Care Pain Med 2019; 38:451-453. [PMID: 31323318 DOI: 10.1016/j.accpm.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, QLD, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Australia; Critical Care Research Group, Centre of Research Excellence for Advanced Cardiorespiratory Therapies Improving Organ Support (ACTIONS), The University of Queensland, Brisbane, QLD, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia; Faculty of Medicine, The University of Queensland, Brisbane, University of Queensland Centre for Clinical Research (UQCCR), QLD, Australia.
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Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K. Overcoming barriers to optimal drug dosing during ECMO in critically ill adult patients. Expert Opin Drug Metab Toxicol 2019; 15:103-112. [PMID: 30582435 DOI: 10.1080/17425255.2019.1563596] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION One major challenge to achieving optimal patient outcome in extracorporeal membrane oxygenation (ECMO) is the development of effective dosing strategies in this critically ill patient population. Suboptimal drug dosing impacts on patient outcome as patients on ECMO often require reversal of the underlying pathology with effective pharmacotherapy in order to be liberated of the life-support device. Areas covered: This article provides a concise review of the effective use of antibiotics, analgesics, and sedative by characterizing the specific changes in PK secondary to the introduction of the ECMO support. We also discuss the barriers to achieving optimal pharmacotherapy in patients on ECMO and also the current and potential research that can be undertaken to address these clinical challenges. Expert opinion: Decreased bioavailability due to sequestration of drugs in the ECMO circuit and ECMO induced PK alterations are both significant barriers to optimal drug dosing. Evidence-based drug choices may minimize sequestration in the circuit and would enable safety and efficacy to be maintained. More work to characterize ECMO related pharmacodynamic alterations such as effects of ECMO on hepatic cytochrome system are still needed. Novel techniques to increase target site concentrations should also be explored.
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Affiliation(s)
- Vesa Cheng
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia
| | - Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia.,b School of Pharmacy , International Islamic University Malaysia , Kuantan , Malaysia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland , Brisbane , Australia.,c Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Australia.,d Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Australia.,e Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy , The University of Queensland , Brisbane , Australia
| | - Kiran Shekar
- f Adult Intensive Care Services , The Prince Charles Hospital , Chermside , Australia.,g Critical Care Research Group , Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS) and the University of Queensland , Brisbane , Australia.,h Faculty of Health Sciences and Medicine , Bond University , Gold Coast , Australia
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Abdul-Aziz MH, Driver E, Lipman J, Roberts JA. New paradigm for rapid achievement of appropriate therapy in special populations: coupling antibiotic dose optimization rapid microbiological methods. Expert Opin Drug Metab Toxicol 2018; 14:693-708. [PMID: 29865877 DOI: 10.1080/17425255.2018.1484452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Some special patient populations (e.g. critically ill, burns, hematological malignancy, post-major surgery, post-major trauma) have characteristics that lead to higher rates of failure and mortality associated with infection. Choice of effective antibiotics and optimized doses are challenging in these patients that are commonly infected by multidrug-resistant pathogens. Areas covered: A review of the importance of diagnosis and the place of newer microbiological methods (e.g. whole-genome sequencing) to ensure rapid transition from empiric to directed antibiotic therapy is provided. The effects of pathophysiological changes on antibiotic pharmacokinetics are also provided. Expert opinion: Product information dosing regimens do not address the pharmacokinetic alterations that can occur in special patient populations and increase the likelihood of therapeutic failure and the emergence of bacterial resistance. Altered dosing approaches, supplemented with the use of dosing software and therapeutic drug monitoring, may be needed to ensure optimal antibiotic exposure and better therapeutic outcomes in these patients with severe infection. Dose optimization needs to be coupled with advanced microbiological techniques that enable rapid microbiological identification and characterization of resistance mechanism to ensure that maximally effective directed therapy can be chosen.
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Affiliation(s)
- Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Elicia Driver
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Jeffrey Lipman
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,c Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,d School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics , The University of Queensland , Brisbane , Queensland , Australia
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Abdul-Aziz MH, Lipman J, Roberts JA. Identifying "at-risk" patients for sub-optimal beta-lactam exposure in critically ill patients with severe infections. Crit Care 2017; 21:283. [PMID: 29157264 PMCID: PMC5697074 DOI: 10.1186/s13054-017-1871-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 10/24/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Mohd H Abdul-Aziz
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Building 71/918 Royal Brisbane & Women's Hospital, Brisbane, QLD, 4029, Australia.,School of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Jeffrey Lipman
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Building 71/918 Royal Brisbane & Women's Hospital, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Building 71/918 Royal Brisbane & Women's Hospital, Brisbane, QLD, 4029, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
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Sinnah F, Shekar K, Abdul-Aziz MH, Buscher H, Diab SD, Fisquet S, Fung YL, McDonald CI, Reynolds C, Rudham S, Wallis SC, Welch S, Xie J, Fraser JF, Roberts JA. Incremental research approach to describing the pharmacokinetics of ciprofloxacin during extracorporeal membrane oxygenation. CRIT CARE RESUSC 2017; 19:8-14. [PMID: 29084496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Significant interactions between drugs, extracorporeal membrane oxygenation (ECMO) circuits and critical illness may affect the pharmacokinetic properties of antibiotics in critically ill patients receiving ECMO. OBJECTIVE To describe the pharmacokinetic properties of ciprofloxacin during ECMO by integrating pre-clinical findings (ie, ex vivo and in vivo ovine models) to a critically ill patient. DESIGN, PARTICIPANTS AND INTERVENTION An ex vivo model of an ECMO circuit was used to describe ciprofloxacin concentration changes over 24 hours. An in vivo ovine model of ECMO was used to describe the population pharmacokinetic properties of ciprofloxacin in three different groups of sheep, and to investigate sources of pharmacokinetic variability. In the final phase, data from a 39-year-old critically ill man was used to validate the findings from the ovine pharmacokinetic model. RESULTS In the ex vivo model of ECMO circuits, the median concentrations of ciprofloxacin at baseline and at 24 hours after ciprofloxacin infusion were similar. The time course of ciprofloxacin in the in vivo ovine on ECMO model was adequately described by a two-compartment model. The final population primary parameter mean estimates were: clearance (CL), 0.21 L/kg/h (SD, 0.09 L/kg/h) and volume of distribution (Vd), 0.84 L/kg (SD, 0.12 L/kg). In the critically ill ECMO patient, the primary pharmacokinetic parameter estimates were: CL, 0.15 L/kg/h and Vd, 0.99 L/kg. CONCLUSIONS We provide preliminary evidence that ciprofloxacin dosing in ECMO patients should remain in line with the recommended dosing strategies for critically ill patients not receiving ECMO.
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Affiliation(s)
- Fabrice Sinnah
- Burns, Trauma and Critical Care Research Centre, University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.
| | - Kiran Shekar
- Critical Care Research Group, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - Hergen Buscher
- Intensive Care Services, St Vincent's Hospital, Sydney, Australia
| | - Sara D Diab
- Critical Care Research Group, Brisbane, Australia
| | - Stephanie Fisquet
- Burns, Trauma and Critical Care Research Centre, University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - Yoke L Fung
- Critical Care Research Group, Brisbane, Australia
| | | | - Claire Reynolds
- Intensive Care Services, St Vincent's Hospital, Sydney, Australia
| | - Sam Rudham
- Intensive Care Services, St Vincent's Hospital, Sydney, Australia
| | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - Susan Welch
- Intensive Care Services, St Vincent's Hospital, Sydney, Australia
| | - Jiao Xie
- Burns, Trauma and Critical Care Research Centre, University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | | | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
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Sulaiman H, Abdul-Aziz MH, Roberts JA. Pharmacokinetic/Pharmacodynamics-Optimized Antimicrobial Therapy in Patients with Hospital-Acquired Pneumonia/Ventilator-Associated Pneumonia. Semin Respir Crit Care Med 2017; 38:271-286. [PMID: 28578552 DOI: 10.1055/s-0037-1602716] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hospital-acquired pneumonia and ventilator-associated pneumonia continue to cause significant morbidity and mortality. With increasing rates of antimicrobial resistance, the importance of optimizing antibiotic treatment is key to maximize treatment outcomes. This is especially important in critically ill patients in intensive care units, in whom the infection is usually caused by less susceptible organisms. In addition, the marked physiological changes that can occur in these patients can cause serious changes in antibiotic pharmacokinetics which in turn alter the attainment of therapeutic drug exposures. This article reviews the various aspects of the pharmacokinetic changes that can occur in the critically ill patients, the barriers to achieving therapeutic drug exposures in pneumonia for systemically delivered antibiotics, the optimization for commonly used antibiotics in hospital- and ventilator-associated pneumonia, the agents that should be avoided in the treatment regimen, as well as the use of adjunctive therapy in the form of nebulized antibiotics.
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Affiliation(s)
- Helmi Sulaiman
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, Brisbane, Australia.,Infectious Diseases Unit, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, Brisbane, Australia.,School of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, UQ Centre for Clinical Research, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Centre of Translational Pharmacodynamics, The University of Queensland, Brisbane, Australia
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Abdul-Aziz MH, Sulaiman H, Mat-Nor MB, Rai V, Wong KK, Hasan MS, Abd Rahman AN, Jamal JA, Wallis SC, Lipman J, Staatz CE, Roberts JA. Beta-Lactam Infusion in Severe Sepsis (BLISS): a prospective, two-centre, open-labelled randomised controlled trial of continuous versus intermittent beta-lactam infusion in critically ill patients with severe sepsis. Intensive Care Med 2016; 42:1535-1545. [PMID: 26754759 DOI: 10.1007/s00134-015-4188-0] [Citation(s) in RCA: 194] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/10/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE This study aims to determine if continuous infusion (CI) is associated with better clinical and pharmacokinetic/pharmacodynamic (PK/PD) outcomes compared to intermittent bolus (IB) dosing in critically ill patients with severe sepsis. METHODS This was a two-centre randomised controlled trial of CI versus IB dosing of beta-lactam antibiotics, which enrolled critically ill participants with severe sepsis who were not on renal replacement therapy (RRT). The primary outcome was clinical cure at 14 days after antibiotic cessation. Secondary outcomes were PK/PD target attainment, ICU-free days and ventilator-free days at day 28 post-randomisation, 14- and 30-day survival, and time to white cell count normalisation. RESULTS A total of 140 participants were enrolled with 70 participants each allocated to CI and IB dosing. CI participants had higher clinical cure rates (56 versus 34 %, p = 0.011) and higher median ventilator-free days (22 versus 14 days, p < 0.043) than IB participants. PK/PD target attainment rates were higher in the CI arm at 100 % fT >MIC than the IB arm on day 1 (97 versus 70 %, p < 0.001) and day 3 (97 versus 68 %, p < 0.001) post-randomisation. There was no difference in 14-day or 30-day survival between the treatment arms. CONCLUSIONS In critically ill patients with severe sepsis not receiving RRT, CI demonstrated higher clinical cure rates and had better PK/PD target attainment compared to IB dosing of beta-lactam antibiotics. Continuous beta-lactam infusion may be mostly advantageous for critically ill patients with high levels of illness severity and not receiving RRT. Malaysian National Medical Research Register ID: NMRR-12-1013-14017.
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Affiliation(s)
- Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, The University of Queensland, Herston, QLD, 4029, Australia. .,School of Pharmacy, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia.
| | - Helmi Sulaiman
- Infectious Diseases Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd-Basri Mat-Nor
- Department of Anaesthesiology and Intensive Care, School of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
| | - Vineya Rai
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kang K Wong
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd S Hasan
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Azrin N Abd Rahman
- School of Pharmacy, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia.,School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Janattul A Jamal
- Department of Pharmacy, Hospital Tengku Ampuan Afzan, Kuantan, Malaysia
| | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, The University of Queensland, Herston, QLD, 4029, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, The University of Queensland, Herston, QLD, 4029, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Christine E Staatz
- School of Pharmacy, The University of Queensland, Brisbane, Australia.,Australian Centre of Pharmacometrics, Brisbane, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, Level 3, Ned Hanlon Building, Royal Brisbane and Women's Hospital, The University of Queensland, Herston, QLD, 4029, Australia. .,School of Pharmacy, The University of Queensland, Brisbane, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
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Abdul-Aziz MH, Lipman J, Akova M, Bassetti M, De Waele JJ, Dimopoulos G, Dulhunty J, Kaukonen KM, Koulenti D, Martin C, Montravers P, Rello J, Rhodes A, Starr T, Wallis SC, Roberts JA. Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort. J Antimicrob Chemother 2015; 71:196-207. [DOI: 10.1093/jac/dkv288] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/17/2015] [Indexed: 12/13/2022] Open
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Abdul-Aziz MH, McDonald C, McWhinney B, Ungerer JPJ, Lipman J, Roberts JA. Low flucloxacillin concentrations in a patient with central nervous system infection: the need for plasma and cerebrospinal fluid drug monitoring in the ICU. Ann Pharmacother 2014; 48:1380-4. [PMID: 24951308 DOI: 10.1177/1060028014540610] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To report the difficulty in achieving and maintaining target antibiotic exposure in critically ill patients with deep-seeded infections. CASE SUMMARY We present a case of a 36-year-old man who was admitted to the intensive care unit with diffuse central nervous system and peripheral methicillin-sensitive Staphylococcus aureus infection (minimum inhibitory concentration; MIC, 1 µg/mL). Owing to the complicated nature of the infection, sequential concentrations of free flucloxacillin were measured in plasma and cerebrospinal fluid (CSF) and used to direct antibiotic dosing. Unsurprisingly, the trough plasma concentrations of flucloxacillin were below the MIC (0.2-0.4 µg/mL), and the corresponding CSF concentrations were undetectable (<0.1 µg/mL) with standard intermittent bolus dosing of 2 g every 4 hours. By administering flucloxacillin by continuous infusion (CI) and increasing the dose to 20 g daily, the plasma (2.2-5.7 µg/mL) and CSF (0.1 µg/mL) levels were increased, albeit lower than the predefined targets (plasma, 40 µg/mL; CSF, 4 µg/mL). DISCUSSION The presence of physiological changes associated with critical illness-namely, hypoalbuminemia and augmented renal clearance-may significantly alter antibiotic pharmacokinetics, and this phenomenon may lead to suboptimal antibiotic exposure if they are not accounted for. This case also highlights the value of applying CI in such patient groups and demonstrates the significance of monitoring plasma and CSF drug concentrations in optimizing antibiotic delivery. CONCLUSIONS Future research should aim to evaluate the utility of such drug monitoring with regard to patient outcomes and cost-effectiveness.
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Affiliation(s)
| | - Craig McDonald
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | | | - Jeffrey Lipman
- The University of Queensland, Brisbane, Australia Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jason A Roberts
- The University of Queensland, Brisbane, Australia Royal Brisbane and Women's Hospital, Brisbane, Australia
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Roberts JA, Abdul-Aziz MH, Lipman J, Mouton JW, Vinks AA, Felton TW, Hope WW, Farkas A, Neely MN, Schentag JJ, Drusano G, Frey OR, Theuretzbacher U, Kuti JL. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. Lancet Infect Dis 2014; 14:498-509. [PMID: 24768475 DOI: 10.1016/s1473-3099(14)70036-2] [Citation(s) in RCA: 650] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in suboptimum outcomes. In this Review, we explore the challenges related to patients and pathogens that contribute to inadequate antibiotic dosing and discuss how to implement a process for individualised antibiotic therapy that increases the accuracy of dosing and optimises care for critically ill patients. To improve antibiotic dosing, any physiological changes in patients that could alter antibiotic concentrations should first be established; such changes include altered fluid status, changes in serum albumin concentrations and renal and hepatic function, and microvascular failure. Second, antibiotic susceptibility of pathogens should be confirmed with microbiological techniques. Data for bacterial susceptibility could then be combined with measured data for antibiotic concentrations (when available) in clinical dosing software, which uses pharmacokinetic/pharmacodynamic derived models from critically ill patients to predict accurately the dosing needs for individual patients. Individualisation of dosing could optimise antibiotic exposure and maximise effectiveness.
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Affiliation(s)
- Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | - Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Johan W Mouton
- Nijmegen Medical Centre, Radboud University, Nijmegen, Netherlands
| | - Alexander A Vinks
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - William W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Andras Farkas
- Department of Pharmacy, Nyack Hospital, Nyack, NY, USA
| | - Michael N Neely
- Laboratory of Applied Pharmacokinetics, University of Southern California, Los Angeles, CA, USA
| | | | - George Drusano
- Institute for Therapeutic Innovation, College of Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Otto R Frey
- Department of Pharmacy, Heidenheim Hospital, Heidenheim, Germany
| | | | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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