Penetration of Isavuconazole in Ascites Fluid of Critically Ill Patients

Fungal peritonitis is a life-threatening condition which is not only difficult to diagnose, but also to treat. Following recent guidelines, echinocandins and azoles are the recommended antimycotics for the management of intra-abdominal Candida spp. infections, with a favor for echinocandins in critically ill patients. However, the new extended spectrum triazole isavuconazole also has a broad spectrum against Candida spp. Data on its target-site penetration are sparse. Therefore, we assessed isavuconazole concentrations and penetration ratios in ascites fluid of critically ill patients. Obtaining of Isavuconazole plasma and ascites fluid levels as well penetration ratios using paracentesis in critically ill patients. Isavuconazole concentrations were quantified in human plasma and ascites by a liquid chromatography/tandem mass spectrometry (LC-MS/MS) method. Isavuconazole concentrations in plasma and ascites fluid were measured in sixteen critically ill patients. Isavuconazol levels in ascites fluid (1.06 µg/mL) were lower than plasma levels (3.08 µg/mL). Penetration ratio was 36%. In two out of sixteen patients, Candida spp., in detail C. glabrata and C. tropicalis, could be isolated. Cmax/MIC Ratio in plasma of 560 for C. glabrata and 2166 for C. tropicalis could be observed. Following our results, isavuconazole penetrates into ascites. Successful treatment in Candida spp. peritonitis depends on pathogen susceptibility.

In-parallel connected intermittent hemodialysis through ECMO does not affect hemodynamic parameters derived from transpulmonary thermodilution

Introduction:

We report a case of renal replacement therapy (RRT) during extracorporeal membrane oxygenation (ECMO) via a single venous access and analyze the feasibility of transpulmonary thermodilution (TPTD) for hemodynamic monitoring.

Case report:

ECMO and RRT connected into the ECMO-extracorporeal circuit were performed via a single venous access because of multiple venous thromboses. An indicator for TPTD and pulse contour analysis (PCA) was applied into the central venous catheter (CVC) placed in the right vena jugularis. TPTD and PCA demonstrated comparable cardiac index.

Discussion:

Congruent data for TPTD and PCA could be observed during TPTD and PCA measurements before ECMO, after ECMO and during ECMO and RRT. This might be explained by high blood flow having the lowest impact on TPTD by venous drainage in the femoral vein/distal vena cava and the TPTD indicator injection using the jugular CVC, as reported in our case.

Conclusion:

Hemodynamic monitoring using TPTD and PCA during ECMO/RRT is feasible and provides reliable results.