A new HPLC-DAD method for contemporary quantification of 10 antibiotics for therapeutic drug monitoring of critically ill pediatric patients

In vitro elution of amikacin, cefazolin, gentamicin, ampicillin/sulbactam, and meropenem from a commercially available calcium sulfate delivery kit

Introduction

The use of implantable antibiotic beads has become a frequent treatment modality for the management of surgical site infections in human and veterinary medicine. The objective of this study is to describe the elution kinetics of five antibiotics from a commercially available calcium sulfate antibiotic delivery kit. A secondary goal was to compare elution concentrations with minimal inhibitory concentrations (MIC) for commonly encountered bacteria from the University of Florida's veterinary microbiology laboratory database.

Methods

Calcium sulfate powder was combined with amikacin, cefazolin, gentamicin, ampicillin/sulbactam, and meropenem. Triplicates of three antibiotic-loaded beads were immersed in 5 mL of phosphate-buffered saline (PBS) and kept at 37°C under constant agitation. Antibiotic-conditioned PBS was sampled at 14 time points from 1-h to 30 days and analyzed by liquid chromatography to determine the antibiotic concentration.

Results

All beads eluted concentrations of antibiotics for the 30-day sampling period, except for ampicillin/sulbactam, with the most antibiotics being eluted within the first week. The concentration of antibiotics within the eluent within the first 3-9 days (3- and 5-mm beads, respectively) was greater than the MIC of common isolates. The 5 mm bead samples were superior in maintaining higher concentrations for a longer period, compared to the 3-mm beads.

Discussion

CSH beads eluted antibiotics over the 30-day course of the study. Most of the antibiotic elution occurred within the first week and was maintained above the MIC of commonly encountered isolates. This information may be useful for clinical decision making for treatment of local infections encountered in practice.

SERS-based detection of the antibiotic ceftriaxone in spiked fresh plasma and microdialysate matrix by using silver-functionalized silicon nanowire substrates

Therapeutic drug monitoring (TDM) is an important tool in precision medicine as it allows estimating pharmacodynamic and pharmacokinetic effects of drugs in clinical settings. An accurate, fast and real-time determination of the drug concentrations in patients ensures fast decision-making processes at the bedside to optimize the clinical treatment. Surface-enhanced Raman spectroscopy (SERS), which is based on the application of metallic nanostructured substrates to amplify the inherent weak Raman signal, is a promising technique in medical research due to its molecular specificity and trace sensitivity accompanied with short detection times. Therefore, we developed a SERS-based detection scheme using silicon nanowires decorated with silver nanoparticles, fabricated by means of top-down etching combined with chemical deposition, to detect the antibiotic ceftriaxone (CRO) in spiked fresh plasma and microdialysis samples. We successfully detected CRO in both matrices with an LOD of 94 μM in protein-depleted fresh plasma and 1.4 μM in microdialysate.

The Use of Cefiderocol as Salvage Therapy in an Infant Receiving ECMO and Continuous Renal Replacement Therapy

BACKGROUND

Infections caused by antimicrobial-resistant (AMR) pathogens are increasing worldwide, representing a serious global public health issue with high morbidity and mortality rates The treatment of Pseudomonas aeruginosa (PA) infections has become a significant challenge due to its ability to develop resistance to many of the currently available antibiotics, especially in intensive care unit (ICU) settings. Among the very few therapeutic lines available against extensively drug-resistant (XDR)-PA and/or with difficult-to-treat resistance (DTR)-PA, cefiderocol is an injectable siderophore cephalosporin not licensed for use in pediatric patients. There are only a few case reports and two ongoing trials describing the administration of this cephalosporin in infants.

CASE PRESENTATION

This report describes the case of a critically ill 8-month-old girl affected by ventilator-associated pneumonia (VAP) infection complicated by bloodstream infection (BSI) sustained by VIM-producing PA. She was treated with cefiderocol as a salvage therapy during ECMO and CRRT support.

CONCLUSIONS

In healthcare settings, treating multidrug-resistant, Gram-negative bacteria poses a serious challenge, especially in pediatric patients. Our findings suggest that cefiderocol can be considered as an off-label rescue therapy in selected pediatric cases.

Impact of Continuous Kidney Replacement Therapy and Hemoadsorption with CytoSorb on Antimicrobial Drug Removal in Critically Ill Children with Septic Shock: A Single-Center Prospective Study on a Pediatric Cohort

Background: Extracorporeal therapies (ET) are increasingly used in pediatric settings as adjuvant therapeutic strategies for overwhelming inflammatory conditions. Although these treatments seem to be effective for removing inflammatory mediators, their influence on antimicrobials pharmacokinetic should not be neglected. Methods: A prospective observational study of children admitted to the pediatric intensive care unit (PICU) with a diagnosis of sepsis/septic shock. All critically ill children received hemoadsorption treatment with CytoSorb (CS) in combination with CKRT. Therapeutic drug monitoring has been performed on 10 critically ill children, testing four antimicrobial molecules: meropenem, ceftazidime, amikacin and levofloxacin. In order to evaluate the total and isolated CKRT and CS contributions to antibiotic removal, blood samples at each circuit point (post-hemofilter, post-CS and in the effluent line) were performed. Therefore, the clearance and mass Removal (MR) of the hemofilter and CS were calculated. Results: Our preliminary report describes a different impact of CS on these target drugs removal: CS clearance was low for amikacine (6-12%), moderate for ceftazidime (43%) and moderate to high for levofloxacine (52-72%). Higher MR and clearance were observed with CKRT compared to CS. To the best of our knowledge, this is the first report regarding pharmacokinetic dynamics in critically ill children treated with CKRT and CS for septic shock.

The Use of Extraction on C18-Silica-Modified Magnetic Nanoparticles for the Determination of Ciprofloxacin and Ofloxacin in Meat Tissues

A simple, fast, and low-cost method of extraction using magnetic nanoparticles was developed for sample preparation in the determination of ciprofloxacin and ofloxacin in meat tissues with the use of capillary electrophoresis. This study is the first utilization of silica-coated magnetic nanoparticles with attached C18 chains to extract fluoroquinolones from meat tissues. This method is therefore characterized by a very simple sample preparation procedure, but on the other hand, by satisfactory precision and accuracy. Magnetic nanoparticles with an appropriately modified surface were placed in an Eppendorf tube, then conditioned with methanol, next rinsed with water and, finally, a homogenized tissue sample was added. At the neutral pH of the sample solution, these compounds do not have a charge and are able to adsorb on the modified particles. After extraction, the nanoparticles were dried and, then, desorption of analytes was conducted with the use of a mixture of 0.1 mol/L HCl and acetonitrile (1:1). This approach made it possible to purify the sample matrix and to obtain satisfactory LOQ levels for the method using the CE technique with UV-Vis detection. In this method, the LOD and LOQ values for both analytes were 0.04 nmol/g tissue and 0.15 nmol/g tissue, respectively. The calibration curves were linear in the entire concentration range, and the accuracy and the recovery of the method were at the satisfactory levels. The square value of the linear correlation coefficients (R2) for Cpx and Ofx were 0.9995 and 0.9992, respectively. The precision value of the method was within the range of 3-11% and accuracy was in the range of 93-110%.

Preparation of Fe3O4-Reduced Graphene-Activated Carbon from Wastepaper in the Dispersive Solid-Phase Extraction and UHPLC-PDA Determination of Antibiotics in Human Plasma

In this work, a sorbent was prepared from wastepaper samples enriched with iron oxide particles and graphene oxide and used in the solid phase extraction of antibiotics. The precursor underwent a carbothermal reduction to promote the formation of paramagnetic phases useful for the recovery of the sorbent during the analysis, and to disperse and fix graphene and the iron oxide in a durable way throughout the cellulose structure. Characterizations were carried out to evaluate the composition (Raman, XRD and EDX) and the morphological structure (SEM) of the material. A UHPLC-PDA method was developed for the simultaneous determination of antibiotics from different drug families (carbapenems, fluoroquinolones, β-lactams) using a 120 SB-C 18 poroshell column (50 × 2.1 mm I.D., 2.7 um particle size) and a mobile phase consisting of 10 mM acetate buffer at pH 5 (Line A) and acetonitrile (Line B) both containing 0.1% of triethylamine. A gradient elution was used for the separation of the analytes, while for the quantitative analysis each analyte was determined at its maximum wavelength. Several experiments were carried out to evaluate the influence of different parameters involving the dispersive magnetic solid phase extraction of these analytes. Samples were extracted using 25 mg of sorbent at pH 5 and desorbed in 5 min using methanol. We report herein on some of the outstanding advantages of using carbon-based sorbent, such as lower toxicity, scalability, improved absorption capacity, target selectivity and stability in acidic medium. Moreover, from the results obtained it is evident that, despite the use of some recycled materials, the performances obtained were comparable or even superior to the methods reported in the literature.

Concurrent Determination of Tigecycline, Tetracyclines and Their 4-Epimer Derivatives in Chicken Muscle Isolated from a Reversed-Phase Chromatography System Using Tandem Mass Spectrometry

A quantitative and qualitative method using a high-performance liquid chromatography–tandem mass spectrometry (HPLC–MS/MS) detection approach was developed and validated for the analysis of tigecycline, four tetracyclines and their three 4-epimer derivatives in chicken muscle. Samples were extracted repeatedly with 0.1 mol/L Na2EDTA–McIlvaine buffer solution. After vortexing, centrifugation, solid-phase extraction, evaporation and reconstitution, the aliquots were separated using a C8 reversed-phase column (50 mm × 2.1 mm, 5 µm) with a binary solvent system consisting of methanol and 0.01 mol/L trichloroacetic acid aqueous solution. The typical validation parameters were evaluated in accordance with the acceptance criteria detailed in the guidelines of the EU Commission Decision 2002/657/EC and the U.S. Food and Drug Administration Bioanalytical Method Validation 05/24/18. The matrix-matched calibration curve was linear over the concentration range from the limit of quantitation (LOQ) to 400 μg/kg for doxycycline, and the calibration graphs for tetracycline, chlortetracycline, oxytetracycline, their 4-epimer derivatives and tigecycline showed a good linear relationship within the concentration range from the LOQ to 200 μg/kg. The limits of detection (LODs) for the eight targets were in the range of 0.06 to 0.09 μg/kg, and the recoveries from the fortified blank samples were in the range of 89% to 98%. The within-run precision and between-run precision, which were expressed as the relative standard deviations, were less than 5.0% and 6.9%, respectively. The applicability was successfully demonstrated through the determination of residues in 72 commercial chicken samples purchased from different sources. This approach provides a novel option for the detection of residues in animal-derived food safety monitoring.

Use of Antibiotics in Preterm Newborns

Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.

Simple, fast and reliable CE method for simultaneous determination of ciprofloxacin and ofloxacin in human urine

A simple, fast, and accurate capillary zone electrophoresis method has been developed for the determination of ciprofloxacin and ofloxacin. This method uses liquid–liquid extraction. Therefore, it is characterized by a very simple procedure of sample preparation but at the same time satisfactory precision and accuracy. The extraction process of the same urine sample was repeated three times. The extraction protocol was performed each time for 15 min with 1 mL of dichloromethane and chloroform mixture in a 3:1 volume ratio. A 0.1 mol/L phosphate-borate buffer (pH 8.40) was selected as the background electrolyte. UV detection was performed at 288 nm. The separation was carried out at a voltage of 16 kV, at a temperature of 25 °C. Experimentally evaluated LOQ values for ciprofloxacin and ofloxacin were 0.2 nmol/mL urine and 0.05 nmol/mL urine, respectively. For both analytes the calibration curves exhibited linearity over the entire tested concentration range of 1–6 nmol/mL urine. The precision of the method did not exceed 15%, and the recovery was in the range of 85–115%. The developed and validated procedure was applied to analyze human urine for the content of ciprofloxacin and ofloxacin.

Methods for Determination of Meropenem Concentration in Biological Samples

Measuring the concentration of antibiotics in biological samples allow implementation of therapeutic monitoring of these drugs and contribute to the adjustment of the dosing regimen in patients. This increases the effectiveness of antimicrobial therapy, reduces the toxicity of these drugs and prevents the development of bacterial resistance. This review article summarizes current knowledge on methods for determining concentration of meropenem, an antibiotic drug from the group of carbapenems, in different biological samples. It provides a brief discussion of the chemical structure, physicochemical and pharmacokinetic properties of meropenem, different sample preparation techniques, use of apparatus and equipment, knowledge of the advantages and limitations of available methods, as well as directions in which new methods should be developed. This review should facilitate clinical laboratories to select and apply one of the established methods for measuring of meropenem, as well as to provide them with the necessary knowledge to develop new methods for quantification of meropenem in biological samples according to their needs.

Separation of ampicillin on polar-endcapped phase: Development of the HPLC method to achieve its correct dosage in cardiac surgery

The accurate, simple, and selective reversed phase high performance liquid chromatography (RP-HPLC) has been established and validated for the determination of an antibiotic ampicillin (AMP) in human blood plasma. The SPE extraction was used for the sample preparation. Chromatographic separation was accomplished by a mobile phase containing 15 mM monopotassium phosphate solution of pH 3.3 and methanol (75:25, v/v) in an isocratic mode at a flow rate of 1.4 mL min−1 at 30 °C. The separation was evaluated on a column with a new polar-endcapped C18 stationary phase Arion® Polar C18 or well-known phase Luna® Omega Polar C18. Excellent linearity (R 2 0.9998) was shown over range 10–300 mg L−1 with mean percentage recovery 90%. Peak shapes were symmetrical in both columns, Arion® Polar C18 and Luna® Omega Polar C18, with asymmetry factor of 1.0 and 1.4, tailing factor of 1.0 and 1.2, and retention factor of 4.6 and 5.6, respectively. The Arion® Polar C18 was almost 1.4-fold more effective than Luna® Omega Polar C18 phase. The LOQ for ampicillin was achieved 10 mg L−1 for Luna® Omega Polar C18 and 5 mg L−1 for Arion® Polar C18 using 20 µL of a solution containing 0.24 mg mL−1 of cephalexin as an internal standard.

A number of articles dealing with the determination of ampicillin is limited, therefore, this study showed the HPLC method suitable for the determination of AMP in human blood plasma from patient who underwent elective cardiac surgical revascularization. In addition, the determination of AMP was also performed for the first time using an Arion® Polar C18 column, which effectively separated AMP from other compounds present in human blood plasma. This new polar-endcapped phase can help in separation of polar antibiotics or other polar compounds, which are unsuccessfully separated on conventional C18 column, and thus can help during method development.

Utility of Silver-nanoparticles for Nano Spectrofluorimetric Determination of Meropenem and Ertapenem: Bio-analytical Validation

Bio-analytical, nano-quantitative spectrofluorimetric estimation of two non-classical β-lactam antibiotics; meropenem (MP) and ertapenem (EP) is presented. The method is based on the enhancement of the fluorescence intensity of MP-Eu³⁺/EP-Eu³⁺ with silver nanoparticles (AgNPs). AgNPs were synthesized and characterized by UV and transmission electron microscope (TEM). The plasmon resonance produced an intense absorption maximum at 398.0 nm. TEM micrograph showed the particle morphology with an average particles size of 13.0 ± 2.95 nm. The fluorescence intensities were measured against blank reagents at λem of 396.0 nm and 405.0 nm after excitation at λex 305.0 nm and 303.0 nm for MP and EP, respectively. Under optimum conditions, the relative fluorescence intensity showed a good linear relationship with the concentration ranges of 4.0-14.0 and 4.0 -12.0 ng/mL with excellent correlation coefficients of 0.9998 and 0.9997, and limit of detection of 0.84 and 0.86 ng/mL for MP and EP, respectively. The method was successfully applied for direct analysis of MP and EP in their drug substances and pharmaceutical vials. The significant, sensitivity and practicality of the method facilitated MP detection in real plasma samples. Bio-analytical validation was performed according to FDA. The method was rectilinear over the ranges of, 5.0 -75.0 μg/mL plasma. Interestingly, this described system has a promising benefit for various applications exploiting the dramatically enhanced-fluorescence occurrence.

Simultaneous Determination of Ciprofloxacin and Ofloxacin in Animal Tissues with the Use of Capillary Electrophoresis with Transient Pseudo-Isotachophoresis

We have developed a precise and accurate method for the determination of ciprofloxacin and ofloxacin in meat tissues. Our method utilizes capillary electrophoresis with a transient pseudo-isotachophoresis mechanism and liquid–liquid extraction during sample preparation. For our experiment, a meat tissue sample was homogenized in pH 7.00 phosphate buffer at a ratio of 1:10 (tissue mass: buffer volume; g/mL). The extraction of each sample was carried out twice for 15 min with 600 µL of a mixture of dichloromethane and acetonitrile at a 2:1 volume ratio. We then conducted the electrophoretic separation at a voltage of 16 kV and a temperature of 25 °C using a background electrolyte of 0.1 mol/L phosphate–borate (pH 8.40). We used the UV detection at 288 nm. The experimentally determined LOQs for ciprofloxacin and ofloxacin were 0.27 ppm (0.8 nmol/g tissue) and 0.11 ppm (0.3 nmol/g tissue), respectively. The calibration curves exhibited linearity over the tested concentration range of 2 to 10 nmol/g tissue for both analytes. The relative standard deviation of the determination did not exceed 15%, and the recovery was in the range of 85–115%. We used the method to analyze various meat tissues for their ciprofloxacin and ofloxacin contents.

Synergistic Meropenem/Vaborbactam Plus Fosfomycin Treatment of KPC Producing K. pneumoniae Septic Thrombosis Unresponsive to Ceftazidime/Avibactam: From the Bench to the Bedside

Gram-negative bacilli septic thrombosis (GNB-ST) represents a subtle and often misleading condition, potentially fatal if not recognized early and requiring prolonged antimicrobial therapy and anticoagulation. Herein, reported for the first time, is a very challenging case of Klebsiella producing carbapenemase (KPC)-producing K. pneumoniae (KPC-Kp) ST unresponsive to ceftazidime/avibactam (CZA) relapsed first with meropenem/vaborbactam (MVB) monotherapy and subsequently cured with MVB plus fosfomycin (FOS) combination. The present case highlights the possibility of CZA underexposure on the infected thrombus and the risk of in vivo emergence of CZA resistance in the setting of persistent bacteremia and sub-optimal anticoagulation. Pharmacokinetic analyses showed that both MVB and FOS were in the therapeutic range. In vitro studies demonstrated a high level of MVB + FOS synergism that possibly allowed definitive resolution of the endovascular infection.

Aptamer-Based Detection of Ampicillin in Urine Samples

The misuse of antibiotics in health care has led to increasing levels of drug resistant infections (DRI's) occurring in the general population. Most technologies developed for the detection of DRI's typically focus on phenotyping or genotyping bacterial resistance rather than on the underlying cause and spread of DRI's; namely the misuse of antibiotics. An aptameric based assay has been developed for the monitoring of ampicillin in urine samples, for use in determining optimal antibiotic dosage and monitoring patient compliance with treatment. The fluorescently labelled aptamers were shown to perform optimally at pH 7, ideal for buffered clinical urine samples, with limits of detection as low as 20.6 nM, allowing for determination of ampicillin in urine in the clinically relevant range of concentrations (100 nM to 100 µM). As the assay requires incubation for only 1 h with a small sample volume, 50 to 150 µL, the test would fit within current healthcare pathways, simplifying the adoption of the technology.

Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age

Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.