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Lin CC, Wu JY, Huang PY, Sung HL, Tung YC, Lai CC, Wei YF, Fu PK. Comparing prolonged infusion to intermittent infusion strategies for beta-lactam antibiotics in patients with gram-negative bacterial infections: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2024:1-11. [PMID: 38441052 DOI: 10.1080/14787210.2024.2324940] [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] [Received: 12/30/2023] [Accepted: 02/20/2024] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Our objective is to determine whether prolonged infusion (PI) of beta-lactam antibiotics yields superior outcomes compared to intermittent infusion (II) in patients with Gram-Negative Bacterial (GNB) infections. METHODS We systematically searched papers from PubMed, the Cochrane Library, Embase, and Clinicaltrials.gov, targeting mortality as the primary outcome and looking at the clinical cure rate, hospital and intensive care unit (ICU) stay lengths, antibiotic treatment duration, and mechanical ventilation (MV) duration as secondary outcomes. RESULTS Our meta-analysis of 18 studies, including 5 randomized control trials and 13 observational studies, with a total of 3,035 patients-1,510 in the PI group and 1,525 in the II group, revealed significant findings. PI was associated with reduced mortality (RR, 0.67; 95% CI, 0.55-0.81; p = 0.001; I2 = 4.52%) and a shorter MV duration (SMD, -0.76; 95% CI, -1.37 to -0.16; p = 0.01; I2 = 87.81%) compared to II. However, no differences were found in clinical cure rates, antibiotic treatment duration, length of hospital stay, or length of ICU stay. CONCLUSIONS The PI approach for administering beta-lactam antibiotics in patients with suspected or confirmed GNB infections may be advantageous in reducing mortality rates and the duration of MV when compared to the II strategy.
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Affiliation(s)
- Chih-Chung Lin
- Department of Pharmacy, Taichung Veteran General Hospital Puli Branch, Nantou, Taiwan
| | - Jheng-Yen Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan, Taiwan
| | - Po-Yu Huang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Hui-Lin Sung
- Department of Pharmacy, Taichung Veteran General Hospital Puli Branch, Nantou, Taiwan
| | - Yu-Chun Tung
- Department of Pharmacy, Taichung Veteran General Hospital Puli Branch, Nantou, Taiwan
| | - Chih-Cheng Lai
- Division of Hospital Medicine, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Feng Wei
- Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Pin-Kuei Fu
- Division of Clinical Research, Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, National Chung Hsing University, Taichung, Taiwan
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Lokhandwala A, Patel P, Isaak AK, Faizan Yousaf R, Maslamani ANJ, Khalil SK, Riaz E, Hirani S. Comparison of the Effectiveness of Prolonged Infusion and Intermittent Infusion of Meropenem in Patients With Sepsis: A Meta-Analysis. Cureus 2023; 15:e46990. [PMID: 38022273 PMCID: PMC10640903 DOI: 10.7759/cureus.46990] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
The aim of this study was to compare the clinical effectiveness of prolonged infusion and intermittent infusion of meropenem in patients with sepsis. This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. PubMed, Web of Science, Scopus, and the Cochrane Library were searched without any language or time restrictions, up to September 25, 2023. The primary outcomes assessed in this meta-analysis included clinical success and all-cause mortality. Other outcomes assessed in this study encompassed the mean length of ICU stay. Total eight studies met the eligibility criteria and were included in this meta-analysis. Pooled analysis showed that the clinical success rate was significantly higher in patients receiving prolonged infusion of meropenem compared to intermittent infusion (RR: 1.49, 95% CI: 1.30 to 1.70). All-cause mortality was 24% significantly lower in patients receiving prolonged infusion of meropenem compared to intermittent infusion (RR: 0.76, 95% CI: 0.60 to 0.96). The results suggest that prolonged infusion of meropenem could be a more effective and efficient treatment for sepsis patients. However, more randomized controlled trials are needed to confirm these findings and to establish the optimal dosing and administration schedule for prolonged infusion of meropenem.
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Affiliation(s)
| | | | - Abraham K Isaak
- Telemetry, Sharp Memorial Hospital, San Diego, USA
- Internal Medicine, Orotta School of Medicine and Dentistry, San Diego, ERI
| | | | | | | | - Eman Riaz
- Internal Medicine, Chiniot General Hospital, Karachi, PAK
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Diamantis S, Chakvetadze C, de Pontfarcy A, Matta M. Optimizing Betalactam Clinical Response by Using a Continuous Infusion: A Comprehensive Review. Antibiotics (Basel) 2023; 12:1052. [PMID: 37370371 DOI: 10.3390/antibiotics12061052] [Citation(s) in RCA: 1] [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: 05/24/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Antimicrobial resistance is a major healthcare issue responsible for a large number of deaths. Many reviews identified that PKPD data are in favor of the use of continuous infusion, and we wanted to review clinical data results in order to optimize our clinical practice. METHODOLOGY We reviewed Medline for existing literature comparing continuous or extended infusion to intermittent infusion of betalactams. RESULTS In clinical studies, continuous infusion is as good as intermittent infusion. In the subset group of critically ill patients or those with an infection due to an organism with high MIC, a continuous infusion was associated with better clinical response. CONCLUSIONS Clinical data appear to confirm those of PK/PD to use a continuous infusion in severely ill patients or those infected by an organism with an elevated MIC, as it is associated with higher survival rates. In other cases, it may allow for a decrease in antibiotic daily dosage, thereby contributing to a decrease in overall costs.
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Affiliation(s)
- Sylvain Diamantis
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France
- DYNAMIC Research Unit, Université Paris-Est-Creteil, 94320 Thiais, France
| | | | - Astrid de Pontfarcy
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France
| | - Matta Matta
- Infectious Diseases Unit, Groupe Hospitalier Sud Ile de France, 77000 Melun, France
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Koumaki V, Dokoumetzidis A, Angelerou MGF, Baka S, Balakrishnan I, Tsakris A. Pharmacokinetic/Pharmacodynamic Determination of Systemic MIC Breakpoints for Intermittent, Extended, and Continuous Infusion Dosage Regimens of Mecillinam. Microbiol Spectr 2023; 11:e0344122. [PMID: 36715534 PMCID: PMC10100751 DOI: 10.1128/spectrum.03441-22] [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] [Received: 08/29/2022] [Accepted: 01/10/2023] [Indexed: 01/31/2023] Open
Abstract
Intravenous mecillinam has been used for the treatment of urosepsis at several dosing regimens, including a dose of 1,000 mg three times a day (TID). In the current pharmacokinetic/pharmacodynamic (PK/PD) study, we analyzed intermittent, extended, and continuous infusion regimens of mecillinam to provide dosage recommendations to treat infections caused by Enterobacterales exhibiting relatively higher mecillinam MICs than the wild-type strains. Monte Carlo simulation studies indicated that regimens of 1,000 mg TID and 1,000 to 1,200 mg four times a day (QID) are efficacious against wild-type and extended-spectrum β-lactamase-producing Enterobacterales, respectively. Prolonged infusion regimens (extended and continuous) could cover carbapenemase producers with a higher range of MICs (2 to 8 mg/L). IMPORTANCE Previous studies have shown that intravenous mecillinam might be suitable for treatment of urosepsis. Since multidrug-resistant Enterobacterales are common pathogens in such infections, an effort was made to delineate intermittent, extended, and continuous infusion regimens that could cover pathogens exhibiting relatively higher mecillinam MICs than the wild-type strains. Our PK/PD analysis has shown that mecillinam might be considered a valuable therapeutic option for the treatment of systemic infections caused by extended-spectrum β-lactamase- and carbapenemase-producing Enterobacterales exhibiting mecillinam MICs up to 8 mg/L.
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Affiliation(s)
- Vasiliki Koumaki
- Department of Microbiology, Medical School, University of Athens, Athens, Greece
- Department of Microbiology, Aretaieion Hospital, University of Athens, Athens, Greece
| | | | | | - Stavroula Baka
- Department of Microbiology, Aretaieion Hospital, University of Athens, Athens, Greece
| | - Indran Balakrishnan
- Department of Medical Microbiology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, University of Athens, Athens, Greece
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Warda AEA, Sarhan RM, Al-Fishawy HS, Moharram AN, Salem HF. Continuous Versus Intermittent Linezolid Infusion for Critically Ill Patients with Hospital-Acquired and Ventilator-Associated Pneumonia: Efficacy and Safety Challenges. Pharmaceuticals (Basel) 2022; 15:ph15030296. [PMID: 35337094 PMCID: PMC8949268 DOI: 10.3390/ph15030296] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/20/2022] [Accepted: 02/26/2022] [Indexed: 02/06/2023] Open
Abstract
High variability of linezolid blood concentrations with partial subtherapeutic levels was observed in critically ill patients who received a standard intravenous dose of linezolid, contributing to drug resistance and toxicity. Continuous infusions of linezolid have been suggested as an alternative and provide good serum and alveolar levels without fluctuations in trough concentration. This study aimed to assess the effectiveness and safety of continuous linezolid infusion versus the standard regimen in critically ill patients. A prospective randomized controlled study was conducted on 179 patients with nosocomial pneumonia. Patients were randomized into two groups. The first group received IV linezolid 600 mg twice daily, while the second group received 600 mg IV as a loading dose, followed by a continuous infusion of 1200 mg/day (50 mg/h) for at least 8−10 days. The continuous infusion group showed a higher clinical cure rate than the intermittent infusion group (p = 0.046). Furthermore, efficacy was proven by greater improvement of P/F ratio (p = 0.030) on day 7 of treatment, a lower incidence of developing sepsis after beginning treatment (p = 0.009), and a shorter time to reach clinical cure (p < 0.001). Hematological parameters were also assessed during the treatment to evaluate the safety between the two groups. The incidence of thrombocytopenia was significantly lower in the continuous infusion group than in the intermittent infusion group. In addition, a stepwise logistic regression model revealed that the intermittent infusion of linezolid was significantly associated with thrombocytopenia (OR =4.128; 95% CI = 1.681−10.139; p =0.001). The current study is the first to assess the clinical aspects of continuous infusion of linezolid beyond pharmacokinetic studies. Continuous infusion of linezolid outperforms intermittent delivery in safety and improves clinical effectiveness in critically ill patients with Gram-positive nosocomial pneumonia.
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Affiliation(s)
- Ahmed E. Abou Warda
- Clinical Pharmacy Department, Faculty of Pharmacy, October 6 University, Giza P.O. Box 12585, Egypt;
| | - Rania M. Sarhan
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef P.O. Box 62514, Egypt
- Correspondence: ; Tel.: +20-100-878-9509
| | - Hussein Saeed Al-Fishawy
- Internal Medicine Department, Faculty of Medicine, Cairo University, Giza P.O. Box 12613, Egypt;
| | - Ayman N. Moharram
- Critical Care Medicine Department, Faculty of Medicine, Cairo University, Giza P.O. Box 12613, Egypt;
| | - Heba F. Salem
- Pharmaceutics and Industrial Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef P.O. Box 62514, Egypt;
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Yu W, Chen Y, Shen P, Ji J, Ying C, Liu Z, Xiong L, Qiu Y, Xiao Y. Antibacterial Activity and Optimal Treatment of Ceftazidime-Avibactam and Aztreonam-Avibactam Against Bloodstream Infections Caused by Carbapenem-Resistant Klebsiella pneumoniae. Front Pharmacol 2022; 12:771910. [PMID: 34970142 PMCID: PMC8712734 DOI: 10.3389/fphar.2021.771910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/07/2021] [Accepted: 11/22/2021] [Indexed: 12/03/2022] Open
Abstract
Objectives: This work was to investigate the activity and optimal treatments of ceftazidime-avibactam (CZA) and aztreonam-avibactam (AZA) against bloodstream infections caused by carbapenem resistant Klebsiella pneumoniae (BSIs-CRKP). Methods: A total of 318 nonduplicate BSIs-CRKP isolates were collected from Blood Bacterial Resistant Investigation Collaborative System (BRICS) program. The minimum inhibitory concentration (MIC) of CZA and AZA were determined by agar dilution method. Carbapenemase genes and multilocus sequence typing were amplified by PCR. Monte Carlo simulation (MCS) was conducted to calculate cumulative fraction of response (CFR) of different CZA or AZA administrations. Results: The MIC90 of CZA and AZA were 128/4 and 1/4 mg/L, respectively. There are 87.4 and 3.5% isolates carried blaKPC-2 and blaNDM-1. A total of 68 ST types were identified and 29 novel ST types. ST11 accounted for 66.6%. Further MCS showed CFR of CZA using two-step infusion therapy (rapid first-step 0.5 h infusion and slow second-step 3 h infusion, TSIT) (2.5 g 0.5 h, 3.75 g every 8 h with 3 h infusion and 3.75 g 0.5 h, 2.5 g every 8 h with 3 h infusion) was above 89%. The CFR of AZA with TSIT was above 96%. Conclusion: TSIT with sufficient pharmacokinetic conditions could be useful for enhancing the therapeutic efficacy of CZA and AZA against BSIs-CRKP.
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Affiliation(s)
- Wei Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yunbo Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ping Shen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinru Ji
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chaoqun Ying
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhiying Liu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Luying Xiong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yunqing Qiu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Rafailidis PI, Falagas ME. Benefits of prolonged infusion of beta-lactam antibiotics in patients with sepsis: personal perspectives. Expert Rev Anti Infect Ther 2020; 18:957-966. [PMID: 32564641 DOI: 10.1080/14787210.2020.1776113] [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: 10/24/2022]
Abstract
INTRODUCTION In the current era of relatively scarce antibiotic production and significant levels of antimicrobial resistance, optimization of pharmacokinetics and pharmacodynamics of antibiotic therapy is mandatory. Prolonged infusion of beta-lactam antibiotics in comparison to the intermittent infusion has the theoretical advantage of better patient outcomes. Apparently, conflicting data in the literature possibly underestimate the benefits of prolonged infusion of antibiotic treatment. AREAS COVERED We provide our perspective on the subject based on our experience and by critically evaluating literature data. EXPERT OPINION COMMENTARY In our opinion, the available data are suggestive of the beneficial role of prolonged infusion of beta-lactams in regard to piperacillin/tazobactam and carbapenems after administering a loading dose. While more data from randomized controlled trials are necessary to solidify or negate the evident benefits of prolonged infusion of the aforementioned antibiotics, clinicians should strongly consider this mode of administration of relevant antibiotics, especially in patients with severe infections.
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Affiliation(s)
- Petros I Rafailidis
- School of Medicine, Democritus University of Thrace , Alexandroupolis, Greece.,Alfa Institute of Biomedical Sciences (AIBS) , Athens, Greece
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS) , Athens, Greece.,Department of Internal Medicine - Infectious Diseases, Henry Dunant Hospital Center , Athens, Greece.,Department of Medicine, Tufts University School of Medicine , Boston, MA, USA
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Gwee A, Cranswick N, Donath SM, Hunt R, Curtis N. Protocol for a randomised controlled trial of continuous infusions of vancomycin to improve the attainment of target vancomycin levels in young infants: The VANC trial. BMJ Open 2018; 8:e022603. [PMID: 30391914 PMCID: PMC6231575 DOI: 10.1136/bmjopen-2018-022603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Vancomycin is frequently used in the treatment of late-onset sepsis in young infants and is routinely administered as intermittent infusions (IIV); however, existing IIV dosing guidelines achieve target vancomycin levels in less than half of infants. Continuous infusions of vancomycin (CIV) are an attractive alternative as adult studies report a higher attainment of target vancomycin levels, simpler drug monitoring and fewer drug side effects. METHODS This is a multicentre, randomised controlled trial in which 200 young infants (aged 0-90 days) requiring vancomycin will be randomised to CIV or IIV for a duration determined by the treating clinician. Vancomycin levels will be measured immediately after the first dose in both arms. Trough and peak levels will be determined in the IIV arm and steady-state levels 18-30 hours after commencement of infusion will be measured in the CIV arm. Full blood count, urea and electrolytes, and C reactive protein level will be monitored throughout treatment. For all Gram-positive bacteria isolated from blood culture, a vancomycin Etest will be done to determine the minimum inhibitory concentration of the bacterium. ANALYSIS Primary outcome: the proportion of infants with levels within target range at their first steady-state concentration. SECONDARY OUTCOMES (1) the proportion of drug-related adverse effects; (2) the time to achieve target levels in the blood; (3) the pharmacodynamics of vancomycin (using non-linear mixed effect modelling). ETHICS AND DISSEMINATION The study has been approved by The Royal Children's Hospital Melbourne Human Research Ethics Committee (HREC) (No. 34030) and the South Eastern Sydney Local Health District HREC (SSA 16/G/335). Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02210169.
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Affiliation(s)
- Amanda Gwee
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Noel Cranswick
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Susan M Donath
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Rodney Hunt
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Nigel Curtis
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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Ahmed N, Jen SP, Altshuler D, Papadopoulos J, Pham VP, Dubrovskaya Y. Evaluation of Meropenem Extended Versus Intermittent Infusion Dosing Protocol in Critically Ill Patients. J Intensive Care Med 2018; 35:763-771. [PMID: 29954243 DOI: 10.1177/0885066618784264] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 12/31/2022]
Abstract
Extended infusion (EI) administration of β-lactams can improve target attainment in critically ill patients with altered pharmacokinetics/pharmacodynamics. To optimize meropenem dosing in patients with severe sepsis/septic shock, our Antimicrobial Stewardship Program implemented a EI meropenem (EIM) protocol in an 18-bed Medical Intensive Care Unit in March 2014. In this retrospective study, we compared intensive care unit (ICU) mortality and clinical response in patients who received meropenem for ≥72 hours administered per EIM protocol of 1 g over 3 hours every 8 hours versus intermittent infusion (IIM) protocol of 500 mg over 30 minutes every 6 hours. Age, weight, comorbidities, severity of illness, and vasopressor use were comparable between groups (EIM protocol n = 52, IIM protocol n = 96). The IIM protocol group had higher rates of renal dose adjustment at meropenem initiation. Among 56 identified gram-negative (GN) pathogens, 94% had meropenem minimal inhibitory concentration ≤0.25 mg/L. The ICU mortality was lower (19 vs 37%; P = .032) and clinical response was higher (83% vs 46%; P < .01) in the EIM protocol versus IIM protocol group. Total vasopressor days were shorter (2 vs 3 days; P = .038), and white blood cell normalization rate was higher (87% vs 51%; P < .01) in the EIM protocol versus IIM protocol group. There was no difference in days of mechanical ventilation, duration of therapy, and ICU stay. The IIM protocol was also identified as an independent risk factor associated with ICU mortality (hazard ratio: 3.653, 95% confidence interval: 1.689-7.981; P = .001) after adjusting for Sequential Organ Failure Assessment score. In this cohort of patients with severe sepsis/septic shock and highly susceptible GN pathogens, there was improved mortality and clinical response in the EIM protocol group.
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Affiliation(s)
- Nabeela Ahmed
- Department of Pharmacy, NYU Langone Health, New York, NY, USA
| | - Shin-Pung Jen
- Division of Infectious Diseases, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Diana Altshuler
- Division of Infectious Diseases, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - John Papadopoulos
- Division of Infectious Diseases, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Vinh P Pham
- Division of Infectious Diseases, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - Yanina Dubrovskaya
- Division of Infectious Diseases, Department of Medicine, NYU Langone Health, New York, NY, USA
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10
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Ibrahim MM, Tammam TF, Ebaed MED, Sarhan HA, Gad GF, Hussein AK. Extended infusion versus intermittent infusion of imipenem in the treatment of ventilator-associated pneumonia. Drug Des Devel Ther 2017; 11:2677-2682. [PMID: 28919718 PMCID: PMC5593413 DOI: 10.2147/dddt.s143021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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] [Indexed: 11/29/2022] Open
Abstract
Background Mechanical ventilation support can be the main source of ventilator-associated pneumonia (VAP). VAP is a serious infection that may be associated with dangerous gram-negative bacteria mainly, and it leads to an increase in the mortality in the intensive care unit (ICU). Imipenem is one of the strongest antibiotics now available for treating VAP which is associated with gram-negative and gram-positive bacteria, and it belongs to beta-lactam antibiotic group (carbapenem). Objective This study tried to investigate the efficacy of imipenem against VAP when it was infused within 180 min versus the efficacy when it was infused within 30–60 min. Setting This study was conducted in main ICU in general hospital which consists of surgical and medical beds within 2 years. One hundred and eighty-seven patients were enrolled on it. Method This study is a retrospective cohort which was conducted within 2 years. The efficacy of imipenem which was administered by intermittent infusion (30–60 min) within first year was compared with the efficacy of imipenem which was administered by extended infusion (180 min) within second year in the field of VAP curing and cost reduction. All data were collected retrospectively from patient medical files and were statistically analyzed by SPSS version 20. Main outcome The study was designed to measure clinical and cost reduction outcomes, mortality and hospital stay. Results The results indicated that there is a significant decrease in mortality, number of recurrent infection, and ICU stay length, and the number of mechanical ventilator days was associated with extended imipenem infusion during the second year of the study. Conclusion The use of imipenem with extended infusion over 3 hours enhances its clinical outcomes in the treatment of VAP.
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Affiliation(s)
- Mohamed M Ibrahim
- Department of Clinical Pharmacy, Faculty of Pharmacy, Minia University, Minia, Egypt
| | - Tarek Fouad Tammam
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | | | - Gamal F Gad
- Department of Microbiology and Immunology, Faculty of Pharmacy, Minia University, Minia, Egypt
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Malekolkottab M, Khalili H, Mohammadi M, Ramezani M, Nourian A. Metoclopramide as intermittent and continuous infusions in critically ill patients: a pilot randomized clinical trial. J Comp Eff Res 2017; 6:127-136. [PMID: 28114798 DOI: 10.2217/cer-2016-0067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 12/26/2022] Open
Abstract
AIM Metoclopramide is commonly used as a prokinetic agent in critically ill patients with enteral feeding intolerance. In this study, noninferiority of metoclopramide as intermittent versus continuous infusion was examined in critically ill patients with enteral feeding intolerance. METHODS Forty critically ill adults patients were assigned to receive metoclopramide as either intermittent (10 mg every 6 h) or continuous (2 mg/h) infusion. Frequency of feeding intolerance and adverse effects of metoclopramide were assessed during 7 days of study. RESULTS Number of patients with feeding intolerance during different times of the course was not different between the groups. Although not statistically significant, diarrhea and cardiac rhythm were more common in continuous than intermittent infusion group. CONCLUSION Continuous and intermittent infusions of metoclopramide showed equivalent effectiveness in critically ill patients.
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Affiliation(s)
- Masoume Malekolkottab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mohammadi
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Ramezani
- Department of Intensive Care Unit, Imam Khomeini Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Anahid Nourian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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12
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Demirel B, İmamoglu E, Gursoy T, Demirel U, Topçuoglu S, Karatekin G, Ovali F. Comparison of intermittent versus continuous vancomycin infusion for the treatment of late-onset sepsis in preterm infants. J Neonatal Perinatal Med 2016; 8:149-55. [PMID: 26410440 DOI: 10.3233/npm-15814103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 12/18/2022]
Abstract
BACKGROUND Vancomycin a frequently used antimicrobial for the treatment of late-onset neonatal sepsis. It can be infused either intermittently or continuously, however, there is no consensus on the optimal dosing regimen. AIM To evaluate microbiological outcomes, clinical response and adverse events of vancomycin when administered via continuos intravenous infusion. METHODS The files of preterm infants (<34 weeks), who received either intermittent (group I, n = 41) or continuous (group II, n = 36) vancomycin infusion for the treatment of late-onset sepsis, were investigated retrospectively. Clinical and demographic features were recorded. RESULTS Clinical improvement rates, Töllner scores and microbiological outcomes did not differ significantly between groups. At 48th hour of vancomycin infusion, 52.8% of infants achieved therapeutic concentrations of vancomycin in group II compared with 34.1% of patients in group I (p = 0.002). Thirty-nine percent of infants in group I had supratherapeutic concentrations of vancomycin at 48th hour compared with 5.6% in group II (p = 0.002). Dose adjustment rate in group I did not differ than group II (65.9% vs. 52.8% respectively, p = 0.3). However, when we subdivide group I into two according to dosing intervals, dose adjustment rates were more common in infants with a gestational age <29 weeks for whom intermittent infusion was performed in 18 hours intervals (92.9% vs 51.9% , p = 0.014). CONCLUSION In preterm infants, continuous and intermittent infusions of vancomycin have similar clinical efficacies. Continuous infusion is well-tolerated and require less blood sampling compared to intermittent infusion especially in infants less than 29 weeks of gestational age.
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Affiliation(s)
- B Demirel
- Zeynep Kamil Maternity and Childrens' Training and Research Hospital, Neonatal Intensive Care Unit, Istanbul, Turkey
| | - E İmamoglu
- Zeynep Kamil Maternity and Childrens' Training and Research Hospital, Neonatal Intensive Care Unit, Istanbul, Turkey
| | - T Gursoy
- Koc University School of Medicine, Department of Pediatrics, Neonatal Intensive Care Unit, Istanbul, Turkey
| | - U Demirel
- Yakacık Maternity and Childrens' Hospital, Istanbul, Turkey
| | - S Topçuoglu
- Zeynep Kamil Maternity and Childrens' Training and Research Hospital, Neonatal Intensive Care Unit, Istanbul, Turkey
| | - G Karatekin
- Zeynep Kamil Maternity and Childrens' Training and Research Hospital, Neonatal Intensive Care Unit, Istanbul, Turkey
| | - F Ovali
- Zeynep Kamil Maternity and Childrens' Training and Research Hospital, Neonatal Intensive Care Unit, Istanbul, Turkey
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13
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Kirschbaum MH, Frankel P, Synold TW, Xie Z, Yen Y, Popplewell L, Chen R, Aljitawi O, Tuscano JM, Chan KK, Newman EM. A phase I pharmacodynamic study of GTI-2040, an antisense oligonucleotide against ribonuclotide reductase, in acute leukemias: a California Cancer Consortium study. Leuk Lymphoma 2016; 57:2307-14. [PMID: 26895565 DOI: 10.3109/10428194.2016.1146947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We performed a phase I study of GTI-2040, an antisense oligonucleotide against ribonucleotide reductase mRNA, on a novel dosing schedule of days 1-4 and 15-18 by continuous infusion to examine efficacy and tolerability in patients with leukemia. A dose of 11 mg/kg/d was safely reached. Dose-limiting toxicities (DLTs) at the higher levels included elevated troponin I and liver function enzymes. There were no objective responses to GTI-2040 in this study; 7/24 patients were able to complete the predetermined three infusion cycles. Pharmacokinetic and pharmacodynamic studies were performed, indicating a trend towards increasing intracellular drug levels and decreasing RRM2 gene expression with increasing doses. This dose schedule may be considered if appropriate combinations are identified in preclinical studies.
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Affiliation(s)
| | - Paul Frankel
- a City of Hope Comprehensive Cancer Center , Duarte , CA , USA
| | | | - Zhiliang Xie
- b Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | - Yun Yen
- a City of Hope Comprehensive Cancer Center , Duarte , CA , USA
| | | | - Robert Chen
- a City of Hope Comprehensive Cancer Center , Duarte , CA , USA
| | - Omar Aljitawi
- a City of Hope Comprehensive Cancer Center , Duarte , CA , USA
| | - Joseph M Tuscano
- c Davis Comprehensive Cancer Center, University of California , Sacramento , CA , USA
| | - Kenneth K Chan
- b Ohio State University Comprehensive Cancer Center , Columbus , OH , USA
| | - Edward M Newman
- a City of Hope Comprehensive Cancer Center , Duarte , CA , USA
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14
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Kwee F, Walker SAN, Elligsen M, Palmay L, Simor A, Daneman N. Outcomes in Documented Pseudomonas aeruginosa Bacteremia Treated with Intermittent IV Infusion of Ceftazidime, Meropenem, or Piperacillin-Tazobactam: A Retrospective Study. Can J Hosp Pharm 2015; 68:386-94. [PMID: 26478584 DOI: 10.4212/cjhp.v68i5.1485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
BACKGROUND Pseudomonas aeruginosa, one of the leading causes of nosocomial gram-negative bloodstream infections, is particularly difficult to treat because of its multiple resistance mechanisms combined with a lack of novel antipseudomonal antibiotics. Despite knowledge of time-dependent killing with ß-lactam antibiotics, most hospitals in Canada currently administer ß-lactam antibiotics by intermittent rather than extended infusions. OBJECTIVES To determine clinical outcomes, microbiological outcomes, total hospital costs, and infection-related costs for patients with P. aeruginosa bacteremia who received intermittent IV administration of antipseudomonal ß-lactam antibiotics in a tertiary care institution. METHODS For this retrospective descriptive study, data were collected for patients who were admitted between March 1, 2005, and March 31, 2013, who had P. aeruginosa bacteremia during their admission, and who received at least 72 h of treatment with ceftazidime, meropenem, or piperacillin-tazobactam. Clinical and microbiological outcomes were determined, and total and infection-related hospital costs were calculated. RESULTS A total of 103 patients were included in the analysis, of whom 79 (77%) experienced clinical cure. In addition, bacterial eradication was achieved in 41 (87%) of the 47 patients with evaluable data for this outcome. Twenty-eight (27%) of the 103 patients died within 30 days of discontinuation of antipseudomonal ß-lactam antibiotic therapy. The median total cost of the hospital stay was $121 718, and the median infection-related cost was $29 697. CONCLUSIONS P. aeruginosa bacteremia is a clinically significant nosocomial infection that continues to cause considerable mortality and health care costs. To the authors' knowledge, no previous studies have calculated total and infection-related hospital costs for treatment of P. aeruginosa bacteremia with intermittent infusion of antipseudomonal ß-lactam antibiotics, with characterization of cost according to site of acquisition of the infection. This study may provide important baseline data for assessing the impact of implementing extended-infusion ß-lactam therapy, antimicrobial stewardship, and infection control strategies targeting P. aeruginosa infection in hospitalized patients.
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Affiliation(s)
- Francine Kwee
- BSc(Hons), BScPhm, ACPR, was, at the time of this study, a General Practice Pharmacy Resident at Sunnybrook Health Sciences Centre, Toronto, Ontario. She is now with the Department of Pharmacy, St Michael's Hospital, Toronto, Ontario
| | - Sandra A N Walker
- BSc, BScPhm, ACPR, PharmD, FCSHP, is with the Department of Pharmacy, and Division of Infectious Diseases, Sunnybrook Health Sciences Centre, and the Leslie L Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Marion Elligsen
- BScPhm, ACPR, is with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Lesley Palmay
- BSc, BScPhm, MSc, ACPR, is with the Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Andrew Simor
- MD, FRCPC, is with the Department of Microbiology and the Division of Infectious Diseases, Sunnybrook Health Sciences Centre, and the Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Nick Daneman
- MD, MSc, FRCPC, is with the Division of Infectious Diseases, Sunnybrook Health Sciences Centre, and the Faculty of Medicine, University of Toronto, Toronto, Ontario
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15
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Prescott WA, Gentile AE, Nagel JL, Pettit RS. Continuous-infusion antipseudomonal Beta-lactam therapy in patients with cystic fibrosis. P T 2011; 36:723-763. [PMID: 22346306 PMCID: PMC3278169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE We sought to evaluate the pharmacokinetics, efficacy, safety, stability, pharmacoeconomics, and quality-of-life effects of continuous-infusion antipseudomonal beta-lactam therapy in patients with cystic fibrosis (CF). DATA SOURCES Literature retrieval was accessed through Medline (from 1950 to December 2010) using the following terms: cystic fibrosis; beta-lactams or piperacillin or ticarcillin or cefepime or ceftazidime or doripenem or meropenem or imipenem/cilastin or aztreonam; continuous infusion or constant infusion; drug stability; economics, pharmaceutical; and quality of life. In addition, reference citations from identified publications were reviewed. STUDY SELECTION AND DATA EXTRACTION We evaluated all articles in English identified from the data sources. DATA SYNTHESIS Patients with CF often harbor colonies of multidrug-resistant organisms, increasing the risk of suboptimal dosing and failure to meet the time above the minimum inhibitory concentration (T > MIC) pharmacodynamic targets. The pharmacokinetics of continuous-infusion antipseudomonal beta-lactam therapy in CF maintains serum concentrations above the MIC of susceptible strains and is more likely than intermittent infusion to achieve optimal T > MIC targets for some intermediate and resistant strains of Pseudomonas aeruginosa. Three noncomparative and four comparative studies have assessed the efficacy and safety of continuous-infusion antipseudomonal beta-lactam therapy during CF pulmonary exacerbations. Ceftazidime, the most extensively studied antibiotic for continuous infusion in CF, has been shown to improve forced expiratory volume in 1 second (FEV(1)), to improve forced vital capacity (FVC), and to extend the time between pulmonary exacerbations. Continuous-infusion cefepime has been studied in a small number of patients, and a trend toward improved pulmonary function has been observed. Continuous-infusion antipseudomonal beta-lactam therapy appears to be well tolerated, although most of the data pertain to ceftazidime. Because continuous infusion may necessitate that patients wear a portable pump in close proximity to the body, the stability of the antibiotic at body temperature must be considered. Several beta-lactams have good stability at body temperature (piperacillin/tazobactam, ticarcillin/clavulanate, and aztreonam) or acceptable if the medication cartridge is changed twice daily (cefepime and doripenem), whereas other beta-lactams have acceptable 24-hour stability only at lower temperatures (cefepime, ceftazidime, doripenem, and meropenem). Although no pharmacoeconomic studies have evaluated the cost-benefit of continuous infusion versus intermittent infusion in patients with CF, the potential medication cost reduction appears to be considerable. There is little information regarding the impact of continuous infusion on quality of life in patients with CF. CONCLUSION Efficacy and safety studies suggest that ceftazidime, administered as a continuous infusion for the treatment of CF pulmonary exacerbations, is safe and effective; has the potential to reduce the costs of treatment; and is preferred to intermittent infusion among patients treated at home. Continuous-infusion ceftazidime may therefore be an alternative to traditional dosing on a case-by-case basis, such as for patients with multidrug-resistant isolates of P. aeruginosa. Treatment with continuous-infusion ceftazidime at home may be considered in such a case, assuming resources and support equivalent to the hospital setting can be ensured. Additional studies assessing the safety and efficacy of other antipseudomonal beta-lactams, when administered as a continuous infusion, during CF pulmonary exacerbations are needed.
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