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Novy E, Liu X, Hernández-Mitre MP, Belveyre T, Scala-Bertola J, Roberts JA, Parker SL. Population pharmacokinetics of prophylactic cefoxitin in elective bariatric surgery patients: a prospective monocentric study. Anaesth Crit Care Pain Med 2024; 43:101376. [PMID: 38494157 DOI: 10.1016/j.accpm.2024.101376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/19/2024] [Accepted: 03/12/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND This study describes the population pharmacokinetics of cefoxitin in obese patients undergoing elective bariatric surgery and evaluates different dosing regimens for achievement of pre-defined target exposures. METHODS Serial blood samples were collected during surgery with relevant clinical data. Total serum cefoxitin concentrations were measured by chromatographic assay and analysed using a population PK approach with Pmetrics®. The cefoxitin unbound fraction (fu) was estimated. Dosing simulations were performed to ascertain the probability of target attainment (PTA) to achieve cefoxitin fu above minimum inhibitory concentrations (MIC) from surgical incision to wound closure. Fractional target attainment (FTA) was calculated against MIC distributions of common pathogens. RESULTS A total of 123 obese patients (median BMI 44.3 kg/m2) were included with 381 cefoxitin concentration values. Cefoxitin was best described by a one-compartment model, with a mean clearance and volume of distribution of 10.9 ± 6.1 L/h and 23.4 ± 10.5 L, respectively. In surgery <2 h, a 2 and a 4 g doses were sufficient for an MIC up to 4 and 8 mg/L (fu 50%), respectively. In prolonged surgery (2-4 h), only continuous infusion enabled optimal PTA for an MIC up to 16 mg/L. Optimal FTAs were obtained against Staphylococcus aureus and Escherichia Coli only when simulating with 50% cefoxitin protein binding (intermittent regimen) and regardless of the protein binding for the continuous infusion. CONCLUSION Intermittent dosing regimens resulted in optimal FTAs against susceptible MIC distributions of S. aureus and E. coli when simulating with 50% cefoxitin protein binding. Continuous infusion of cefoxitin may improve FTA regardless of protein binding. STUDY REGISTRATION Registration on ClinicalTrials.gov, NCT03306290.
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Affiliation(s)
- Emmanuel Novy
- Department of Anaesthesiology Critical Care and Perioperative Medicine, Nancy University Hospital, University of Lorraine, Vandoeuvre-Lès-Nancy, 54500, France; UR SIMPA, Université de Lorraine, 54000, Nancy, France; UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia.
| | - Xin Liu
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia
| | | | - Thibaut Belveyre
- Department of Anaesthesiology Critical Care and Perioperative Medicine, Nancy University Hospital, University of Lorraine, Vandoeuvre-Lès-Nancy, 54500, France
| | - Julien Scala-Bertola
- Department of Clinical Pharmacology and Toxicology, Nancy University Hospital, Vandoeuvre-Lès-Nancy, 54500, France; CNRS, IMoPA, Université de Lorraine, 54000, Nancy, France
| | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia; Division of Anaesthesiology Critical Care Emergency & Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, 30029, France; Herston Infectious Disease Institute (HeiDI), Metro North Health, Brisbane, Australia
| | - Suzanne L Parker
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, 4029, Australia
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Liu HX, Tang BH, van den Anker J, Hao GX, Zhao W, Zheng Y. Population pharmacokinetics of antibacterial agents in the older population: a literature review. Expert Rev Clin Pharmacol 2024; 17:19-31. [PMID: 38131668 DOI: 10.1080/17512433.2023.2295009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Older individuals face an elevated risk of developing bacterial infections. The optimal use of antibacterial agents in this population is challenging because of age-related physiological alterations, changes in pharmacokinetics (PK) and pharmacodynamics (PD), and the presence of multiple underlying diseases. Therefore, population pharmacokinetics (PPK) studies are of great importance for optimizing individual treatments and prompt identification of potential risk factors. AREA COVERED Our search involved keywords such as 'elderly,' 'old people,' and 'geriatric,' combined with 'population pharmacokinetics' and 'antibacterial agents.' This comprehensive search yielded 11 categories encompassing 28 antibacterial drugs, including vancomycin, ceftriaxone, meropenem, and linezolid. Out of 127 studies identified, 26 (20.5%) were associated with vancomycin, 14 (11%) with meropenem, and 14 (11%) with piperacillin. Other antibacterial agents were administered less frequently. EXPERT OPINION PPK studies are invaluable for elucidating the characteristics and relevant factors affecting the PK of antibacterial agents in the older population. Further research is warranted to develop and validate PPK models for antibacterial agents in this vulnerable population.
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Affiliation(s)
- Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo-Hao Tang
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Clinical Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
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Goutelle S, Jullien V, Bru JP, Cattoir V, Gauzit R, Lesprit P, Lina G, Schramm F, Canoui E, Lepeule R. Defining standard and high dosages for β-lactam agents administered by intermittent, prolonged or continuous infusion: a PK/PD simulation study. J Antimicrob Chemother 2023; 78:2762-2769. [PMID: 37796958 DOI: 10.1093/jac/dkad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND The new definitions of antimicrobial susceptibility categories proposed by EUCAST in 2020 require the definition of standard and high dosages of antibiotic. For injectable β-lactams, standard and high dosages have been proposed for short-infusion regimens only. OBJECTIVES To evaluate dosages for β-lactams administered by prolonged infusion (PI) and continuous infusion (CI). METHODS Monte Carlo simulations were performed for seven injectable β-lactams: aztreonam, cefepime, cefotaxime, cefoxitin, ceftazidime, piperacillin and temocillin. Various dosage regimens based on short infusion, PI or CI were simulated in virtual patients. Pharmacokinetic (PK) profiles and PTAs were obtained based on reference population PK models, as well as PK/pharmacodynamic targets and MIC breakpoints proposed by EUCAST. Alternative dosage regimens associated with PTA values similar to those of recommended dosages up to the breakpoints were considered acceptable. RESULTS Adequate PTAs were confirmed for most EUCAST short-infusion dosage regimens. A total of 9 standard and 14 high dosages based on PI (3 to 4 h) or CI were identified as alternatives. For cefepime and aztreonam, only PI and CI regimens could achieve acceptable PTAs for infections caused by Pseudomonas spp.: 2 g q8h as PI of 4 h or 6 g/24 h CI for cefepime; 2 g q6h as PI of 3 h or 6 g/24 h CI for aztreonam. CONCLUSIONS These alternative standard and high dosage regimens are expected to provide antibiotic exposure compatible with new EUCAST definitions of susceptibility categories and associated MIC breakpoints. However, further clinical evaluation is necessary.
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Affiliation(s)
- Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon, Lyon, France
| | - Vincent Jullien
- Unité Fonctionnelle de Pharmacologie, AP-HP, Groupe Hospitalier Paris Seine Saint-Denis, Bondy, F-93140, France
- Département de Pharmacologie, Université Sorbonne Paris Nord, Bobigny, F-93000, France
| | - Jean-Pierre Bru
- Service des Maladies Infectieuses, Centre Hospitalier Annecy Genevois, Pringy Cedex 74374, France
| | - Vincent Cattoir
- Service de Bactériologie-Hygiène Hospitalière, CHU de Rennes, Rennes, F-35033, France
| | - Rémy Gauzit
- Infectiologie Transversale, CHU Cochin, AP-HP, Paris, 75014, France
| | - Philippe Lesprit
- Service des Maladies Infectieuses, CHU Grenoble Alpes, La Tronche, F-38700, France
| | - Gérard Lina
- Institut des Agents Infectieux, Hôpital de la Croix-Rousse, Hospices Civils de Lyon and Equipe Pathogénie des Staphylocoques, Centre International de Recherche en Infectiologie, INSERM U1111, CNRS, UMR 5308, ENS de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Frédéric Schramm
- Laboratory of Bacteriology, FMTS-CHRU Strasbourg, University of Strasbourg, Strasbourg, F67000, France
| | - Etienne Canoui
- Equipe mobile d'infectiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris Centre-Cochin, Paris, F75014, France
| | - Raphael Lepeule
- Unité Transversale de Traitement des Infections, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, F-94010, France
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Yamashiro H, Kasamatsu Y, Anan N, Takemura M, Yamano Y. In vitro efficacy of humanized regimen of flomoxef against extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae. Antimicrob Agents Chemother 2023; 67:e0025823. [PMID: 37610203 PMCID: PMC10508154 DOI: 10.1128/aac.00258-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/28/2023] [Indexed: 08/24/2023] Open
Abstract
This study compared the efficacy of flomoxef with other β-lactam antibiotics against extended-spectrum β-lactamases (ESBL)-producing bacteria of clinical relevance. First, the prevalence and β-lactamase genotypes of ESBL-producing strains among Escherichia coli and Klebsiella pneumoniae isolates collected in Japan from 2004 to 2018 were investigated. High MIC90 values (>64 µg/mL) of ceftriaxone, cefepime, and ceftazidime and low MIC90 values (≤0.06-2 µg/mL) of flomoxef, cefmetazole, and meropenem against both species were observed. Second, a chemostat model was used to analyze the efficacy of humanized regimens of three oxacephem/cephamycin antibiotics (flomoxef, cefmetazole, cefoxitin) and two other antibiotics (meropenem and piperacillin/tazobactam) in suppressing the growth of five ESBL-producing E. coli and two K. pneumoniae strains. Flomoxef, piperacillin/tazobactam, and meropenem showed good bactericidal effects with >4 log10 CFU/mL reduction without bacterial regrowth at 24 h even when the MIC of test isolates was >MIC90. Cefmetazole and cefoxitin resulted in regrowth of test isolates with MIC ≥MIC90 at 24 h. Cefmetazole, cefoxitin, flomoxef, and meropenem showed increased MICs for regrown samples. A clear relationship between the proportion of time that the free drug concentration exceeded the MIC (%fT>MIC) and antibiotic efficacy was found for flomoxef, cefoxitin, and cefmetazole, and flomoxef had the highest %fT>MIC, whereas discrepancies between Clinical and Laboratory Standards Institute breakpoint and bactericidal activity were observed for cefmetazole. Flomoxef was effective in preventing the growth of all ESBL-producing strains, even those with an MIC eight times the MIC90. Thus, flomoxef may be a good alternative to meropenem in context of carbapenems sparing stewardship.
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Affiliation(s)
- Hidenori Yamashiro
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Toyonaka, Osaka, Japan
| | - Yu Kasamatsu
- Department of Infection Control and Laboratory Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naomi Anan
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Toyonaka, Osaka, Japan
| | - Miki Takemura
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Toyonaka, Osaka, Japan
| | - Yoshinori Yamano
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd., Toyonaka, Osaka, Japan
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Chabert P, Provoost J, Cohen S, Dupieux-Chabert C, Bitker L, Ferry T, Goutelle S, Richard JC. Pharmacokinetics, efficacy and tolerance of cefoxitin in the treatment of cefoxitin-susceptible extended-spectrum beta-lactamase producing Enterobacterales infections in critically ill patients: a retrospective single-center study. Ann Intensive Care 2022; 12:90. [PMID: 36175707 PMCID: PMC9522958 DOI: 10.1186/s13613-022-01059-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/01/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cefoxitin is active against some extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE), but has not been evaluated so far in the intensive care unit (ICU) settings. Data upon its pharmacokinetics (PK), tolerance and efficacy in critical conditions are scanty. We performed a retrospective single-center study in a university hospital medical ICU, in subjects presenting with cefoxitin-susceptible ESBL-PE infection and treated with cefoxitin. The primary aim was to determine cefoxitin PK. Secondary endpoints were efficacy, tolerance, and emergence of cephamycin-resistance. RESULTS Forty-one patients were included in this study, mainly with ESBL-PE pneumonia (35 patients, 85%). Cefoxitin was administered during a median [interquartile range (IQR)] duration of 5 [4-7] days. Cefoxitin serum concentrations strongly depended on renal function. Target serum concentration (> 5 × minimum inhibitory concentration (MIC) 24 h after cefoxitin onset was obtained in 34 patients (83%), using a median [IQR] daily dose of 6 [6-6] g with continuous administration. The standard dosage of 6 g/24 h was not sufficient to achieve the PK/PD target serum concentration for MIC up to 4-8 mg/L, except in patients with severe renal impairment and those treated with renal replacement therapy. Treatment failure occurred in 26 cases (63%), among whom 12 patients (29%) died, 13 patients (32%) were switched to alternative antibiotic therapy and 11 patients (27%) presented with relapse of infection with the same ESBL-PE. Serious adverse events attributed to cefoxitin occurred in 7 patients (17%). Acquisition of cephamycin-resistance with the same Enterobacterales was identified in 13 patients (32%), and was associated with underdosage. CONCLUSION Continuous administration of large doses of cefoxitin appears necessary to achieve the PK/PD target in patients with normal renal function. Renal status, MIC determination and therapeutic drug monitoring may be useful for treatment individualization in this setting. The treatment failure rate was 63%. The cefoxitin safety profile was favorable, but we observed a high rate of cephamycin-resistance emergence.
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Affiliation(s)
- Paul Chabert
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France. .,Hospices Civils de Lyon, Maladies Infectieuses et Tropicales, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.
| | - Judith Provoost
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France
| | - Sabine Cohen
- Unité Fonctionnelle de Pharmacologie Spécialisée, Hospices Civils de Lyon, UM de Pharmaco-Toxicologie, Centre Hospitalier Lyon Sud, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite Cedex, France
| | - Céline Dupieux-Chabert
- Hospices Civils de Lyon, Institut Des Agents Infectieux, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France.,CREATIS UMR 5220, INSA-Lyon, CNRS, INSERM, U1294, Université de Lyon, Université Claude Bernard Lyon 1, 69621, Lyon, France
| | - Tristan Ferry
- Hospices Civils de Lyon, Maladies Infectieuses et Tropicales, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France
| | - Sylvain Goutelle
- Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France.,Service de Pharmacie, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France.,UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Jean-Christophe Richard
- Hospices Civils de Lyon, Médecine Intensive - Réanimation, Hôpital de La Croix Rousse, 103 Grande rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, 92 rue Pasteur, CS 30122, 69361, Lyon Cedex 07, France.,Université Claude Bernard Lyon 1, 43 Boulevard du 11 Novembre 1918, 69100, Villeurbanne, France.,CREATIS UMR 5220, INSA-Lyon, CNRS, INSERM, U1294, Université de Lyon, Université Claude Bernard Lyon 1, 69621, Lyon, France
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Takayama Y, Komatsu T, Nakamura T, Tomoda Y, Toda M, Miura H, Sato T, Atsuda K, Okamoto H, Hanaki H. Association of serum and fat tissue antibiotic concentrations with surgical site infections in lower gastrointestinal surgery. Surgery 2022; 171:1000-1005. [PMID: 34772516 DOI: 10.1016/j.surg.2021.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/20/2021] [Accepted: 10/05/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND During surgery, the effectiveness of perioperative prophylactic antibiotic administration against surgical site infections is inferred from serum concentrations and not from tissues where local infections occur. This study aimed to measure the serum and tissue concentrations of cefmetazole in colorectal surgery cases to clarify whether there is an association between the incidence of surgical site infections and antibiotic concentrations. METHODS This prospective cohort study was performed at a single tertiary care center. The data of 105 patients who underwent colorectal surgery between October 2017 and September 2019 were evaluated. The primary outcome was the incidence of surgical site infections. Univariate analysis was performed to investigate the association between surgical site infections, perioperative factors, and the serum and tissue concentrations of cefmetazole. RESULTS The incidence of surgical site infections was 13/105 (12.4%). Cefmetazole concentrations were measured at initial incision (serum; 101 vs 93.1 mg/L, P = .75, subcutaneous fat tissue; 2.8 vs 3.7 mg/g, P = .15), intestinal resection (serum; 35.1 vs 36.7 mg/L, P = .63, mesenteric adipose tissue; 1.3 vs 1.7 mg/g, P = .55), and at skin closure (serum; 34.5 vs 44.8 mg/L, P = .18, subcutaneous fat tissue; 1.0 vs 2.2 mg/g, P = .09). In univariate analysis with P ≤ .10, cefmetazole concentration in subcutaneous fat tissue at skin closure was found to be a significant risk factor for surgical site infections. Age, additional intraoperative administration of cefmetazole, and creatinine clearance were also significant risk factors for the occurrence of surgical site infections. CONCLUSION Low subcutaneous fat cefmetazole concentrations at skin closure during gastrointestinal operations may also be involved in the occurrence of surgical site infections.
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Affiliation(s)
- Yoko Takayama
- Department of Infection Control and Infectious Diseases, Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Kanagawa, Japan; Department of Infection Control and Prevention, Kitasato University Hospital, Kanagawa, Japan.
| | - Toshiaki Komatsu
- Department of Pharmacy, Kitasato University Hospital, Kanagawa, Japan
| | | | - Yoshinori Tomoda
- Laboratory of Clinical Pharmacokinetics, Research and Education Center for Clinical Pharmacy, Kitasato University School of Pharmacy, Kanagawa, Japan
| | - Masaya Toda
- Department of Anesthesiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hirohisa Miura
- Department of Lower Gastrointestinal Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Takeo Sato
- Department of Lower Gastrointestinal Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Koichiro Atsuda
- Pharmacy Practice and Science I, Research and Education Center for Clinical Pharmacy, Kitasato University School of Pharmacy, Tokyo, Japan
| | - Hirotsugu Okamoto
- Department of Anesthesiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hideaki Hanaki
- Omura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
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Belveyre T, Scala-Bertola J, Esposito M, Luc A, Lipman J, Novy E. Influence of the Obesity Phenotype on the Adequacy of Antibiotic Prophylaxis with Cefoxitin for Obese Patients Undergoing Bariatric Surgery: Lessons Learnt and Future Considerations. Eur J Drug Metab Pharmacokinet 2021; 46:479-485. [PMID: 33959888 DOI: 10.1007/s13318-021-00688-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES A high inter-individual variability in pharmacokinetic parameters in obese patients is observed. The objective of this study was to evaluate the effect of obesity parameters on the pharmacokinetics of cefoxitin administered for antibiotic prophylaxis during bariatric surgery. METHODS This a secondary analysis of a pharmacokinetic study involving 174 obese patients scheduled for bariatric surgery and receiving a 4-g dose of cefoxitin. Blood samples were collected at incision and wound closure. The total plasma concentrations were assessed utilising a validated high-performance liquid chromatography-tandem mass spectrometry method. The pharmacokinetic and pharmacodynamic target was defined as an estimated free concentration of cefoxitin at the time of wound closure >8 mg/L. Specific evaluated obesity parameters were fat body mass, fat body mass/height2, lean body mass, lean body mass/height2, visceral adipose tissue and presence of a metabolic syndrome. RESULTS A total of 174 patients (median age 47 years) with a majority of women (75.3%) and a median BMI of 44 kg/m2 were analysed. The percentage of patients who met the pharmacokinetic and pharmacodynamic target was 85.1%. In the whole population, a tendency to fail to reach the target was observed with a higher lean mass over height2 [OR = 0.79; 95% CI (0.62-1.01); P = 0.060]. In the female subgroup, higher lean mass over height2 [OR = 0.63; 95% CI (0.41-0.97); P = 0.037] and the presence of a metabolic syndrome [OR = 0.17; 95% CI (0.03-0.83); P = 0.030] were associated with failure to reach the pharmacokinetic and pharmacodynamic target. CONCLUSION Obese patients with a higher lean mass and a metabolic syndrome could constitute a subgroup at risk for cefoxitin under-dosage.
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Affiliation(s)
- Thibaut Belveyre
- Department of Anaesthesiology, critical care and peri-operative medicine, Surgical Intensive Care Unit JM Picard, University Hospital of Nancy, 54511, Vandœuvre-Lès-Nancy, France.
| | - Julien Scala-Bertola
- Department of Clinical Pharmacology and Toxicology, University Hospital of Nancy, 54000, Nancy, France
- Université de Lorraine, CNRS, IMoPA, 54000, Nancy, France
| | - Mathieu Esposito
- Department of Anaesthesiology, critical care and peri-operative medicine, Surgical Intensive Care Unit JM Picard, University Hospital of Nancy, 54511, Vandœuvre-Lès-Nancy, France
| | - Amandine Luc
- DRCI, MPI department, Methodology, Data Management and Statistic Unit, University Hospital of Nancy, 54511, Vandœuvre-Lès-Nancy, France
| | - Jeffrey Lipman
- University of Queensland Centre of Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Scientific Consultant, Nimes University Hospital, University of Montpellier, Nimes, France
| | - Emmanuel Novy
- Department of Anaesthesiology, critical care and peri-operative medicine, Surgical Intensive Care Unit JM Picard, University Hospital of Nancy, 54511, Vandœuvre-Lès-Nancy, France
- Université de Lorraine, SIMPA, Stress Immunity Pathogens unit, EA 7300, 54000, Nancy, France
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8
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Kim KM, Kim SH, Yun HY, Jung J, Bang JY, Lee EK, Choi BM, Noh GJ. Development of a new pharmacokinetic model for target-concentration controlled infusion of cefoxitin as a prophylactic antibiotic in colorectal surgical patients. Br J Clin Pharmacol 2021; 87:4648-4657. [PMID: 33929765 DOI: 10.1111/bcp.14883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 04/08/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS There are several limitations to the existing method of administering cefoxitin as a prophylactic antibiotic, and the limitations may be overcome by applying the target-concentration controlled infusion (TCI) method. Population pharmacokinetic parameters are required to administer cefoxitin by the TCI method. The aim of this study was to construct a new pharmacokinetic model of cefoxitin for the TCI method in colorectal surgical patients. METHODS In patients undergoing colorectal surgery, 2 g of cefoxitin was dissolved in 50 mL of saline and administered for 10 minutes prior to skin incision. Arterial blood samples were obtained at preset intervals to measure the total and free plasma concentrations of cefoxitin. Population pharmacokinetic analysis was performed using NONMEM software (ICON Development Solutions, Dublin, Ireland). Additionally, stochastic simulation was used to indirectly evaluate the effectiveness of the two administration methods (standard method vs TCI). RESULTS In total, 297 plasma concentration measurements from 31 patients were used to characterize the pharmacokinetics of cefoxitin. A three-compartment mammillary model described the pharmacokinetics of cefoxitin. Body weight and creatinine clearance were significant covariates for clearance. The stochastic simulation showed that when compared with the standard method, the TCI method has a significantly higher fraction of time that the free concentration of cefoxitin is maintained above the minimum inhibitory concentration (P < .001). CONCLUSIONS TCI has the potential to become a new infusion method for patient-tailored dosing in surgical patients. To administer cefoxitin via TCI in clinical practice, the newly constructed pharmacokinetic model should undergo proper external validation.
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Affiliation(s)
- Kyung Mi Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Hoon Kim
- University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho-Yong Yun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji-Yeon Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun-Kyung Lee
- Department of Statistics, Ewha Womans University, Seoul, South Korea
| | - Byung-Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyu-Jeong Noh
- Departments of Anesthesiology and Pain Medicine, Clinical Pharmacology and Therapeutics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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9
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Pilmis B, Mizrahi A, Mory C, Le Monnier A, El Helali N. How to optimize administration of cefoxitin for the treatment of extended spectrum producing Enterobacteriaceae-related infection? Eur J Clin Microbiol Infect Dis 2021; 40:1393-1397. [PMID: 33502648 DOI: 10.1007/s10096-021-04165-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/13/2021] [Indexed: 11/29/2022]
Abstract
Pharmacological and clinical data regarding cefoxitin for the treatment of ESBL-producing Enterobacteriaceae-related infections are limited. We performed a multicentric prospective cohort study to evaluate continuous/prolonged, or intermittent infusion of cefoxitin. We assessed the plasma concentration as a function of the duration of infusion and then performed a simulation of the percentage of patients who would reach the PK/PD targets, set at 100% ƒT> MIC or 100% ƒT>4 MIC. Eighty-one patients were included. All patients were treated with 6 gr./day. MICs to cefoxitin ranged from 0.5 to 64 mg/L. Sixteen (19.7%) patients were infected with strains with cefoxitin MICs ≥ 8 mg/L. In all patients infected with strains with MICs ≤ 6 mg/L, PK/PD objectives (100% ƒT> MIC) were achieved with prolonged or continuous infusion. In contrast, when MICs were 8 mg/L only, continuous infusion was sufficient to achieve the PK/PD objectives (100% ƒT> MIC). Extended infusion of cefoxitin is necessary for the treatment of non-UTI ESBL-related infections.
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Affiliation(s)
- Benoît Pilmis
- Équipe mobile de microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, 75015, Paris, France. .,Bactéries Pathogènes et Santé, Institut Micalis, UMR 1319, INRAe, AgroParisTech, Université Paris-Saclay, Paris, France. .,Service de maladies infectieuses et tropicales, Hôpital Necker-Enfants Malades, Paris, France.
| | - Assaf Mizrahi
- Bactéries Pathogènes et Santé, Institut Micalis, UMR 1319, INRAe, AgroParisTech, Université Paris-Saclay, Paris, France.,Service de microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Céline Mory
- Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Alban Le Monnier
- Bactéries Pathogènes et Santé, Institut Micalis, UMR 1319, INRAe, AgroParisTech, Université Paris-Saclay, Paris, France.,Service de microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France.,Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Najoua El Helali
- Service de microbiologie clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France.,Plateforme de dosage des anti-infectieux, Groupe Hospitalier Paris Saint-Joseph, Paris, France
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10
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Antibiotic prophylaxis with high-dose cefoxitin in bariatric surgery: an observational prospective single center study. Antimicrob Agents Chemother 2019:AAC.01613-19. [PMID: 31591127 DOI: 10.1128/aac.01613-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The optimal dose of cefoxitin for antibiotic prophylaxis in obese patients remains uncertain. We evaluated the adequacy of a 4-gram dosing regimen of cefoxitin against the most frequent pathogens that infect patients undergoing bariatric surgery. METHODS This observational prospective study included obese patients who required bariatric surgery and a 4-gram dose of cefoxitin as an antibiotic prophylaxis. Serum concentrations were measured during surgery (incision, wound closure and in case of reinjection). The pharmacokinetic/pharmacodynamic (PK/PD) target was to obtain free cefoxitin concentrations above 4× MIC, from incision to wound closure (100% ƒT>4xMIC). The targeted MIC was based on the worst-case scenario (the highest ECOFF value of Staphylococcus aureus, Enterobacteriaceae and anaerobic bacteria). The secondary outcomes were the factors related to underdosage. RESULTS Two hundred patients were included. The mean age of the patients was 46 (±12) years-old, and the mean BMI was 45.8 (±6.9) kg/m2 Bypass surgery was the preferred technique (84%). The percentages of patients who met the PK/PD target (100% fT>4xMIC) of cefoxitin were 37.3%, 1.1% and 0% for S. aureus, Enterobacteriaceae and anaerobic bacteria, respectively. BMIs below 50 kg/m2 (OR 0.29, 95% CI [0.11-0.75], P = 0.0107) and a shorter duration of surgery (OR 0.97, 95% CI [0.95-0.99], P = 0.004) were associated with reaching the target concentrations. CONCLUSIONS In obese patients undergoing bariatric surgery, a regimen of 4 grams of cefoxitin led to an inadequate coverage for most common pathogens. A longer surgery duration and BMI over 50 kg/m2 increase the risk of underdosage.
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11
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Cefoxitin Prophylaxis During Pediatric Cardiac Surgery: Retrospective Exploration of Postoperative Trough Levels. Pediatr Infect Dis J 2019; 38:484-489. [PMID: 30169486 DOI: 10.1097/inf.0000000000002179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study aimed to explore inter-individual variability of cefoxitin trough levels, predictors of serum cefoxitin concentration and the probability of target attainment of drug levels above 4 mg/L after pediatric cardiac surgery. METHODS Retrospective study on children scheduled for elective cardiac surgery and having cefoxitin trough levels available up to 24 hours postsurgery. RESULTS Overall, 68 children (9 neonates, 34 infants, 15 children below or equal to 10 years old and 10 patients above this age) were included. Of these, 16 surgeries were performed off cardiopulmonary bypass and 52 were performed on cardiopulmonary bypass. The free cefoxitin concentrations showed a median (interquartile range) concentration of 1.7 (0.6-4.2) mg/L. The range of cefoxitin concentrations showed a 150-fold and 340-fold variability at cardiac intensive care unit admission and after 24 hours, respectively. The pharmacodynamics (PD) targets of free cefoxitin at 100% of the dosing interval, considering Eucast breakpoints for Methicillin Sensitive Staphylococcus Aureus (4 mg/L) and E.Coli (8 mg/L), were obtained in 28% and 16% of patients, respectively. Patient weight (odds ratio, 0.7; 95% confidence interval, 0.62-0.92; P = 0.006) and serum creatinine concentrations (odds ratio, 25; 95% confidence interval, 18-36; P = 0.004) showed a significant relationship with the PD targets. CONCLUSIONS Cefoxitin trough concentrations vary significantly in the first 24 hours after pediatric cardiac surgery. Both serum creatinine and body weight showed independent associations with cefoxitin concentration. The PD target was not obtained in the vast majority of the explored population, regardless of the target bacteria.
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12
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Boisson M, Torres BGS, Yani S, Couet W, Mimoz O, Dahyot-Fizelier C, Marchand S, Grégoire N. Reassessing the dosing of cefoxitin prophylaxis during major abdominal surgery: insights from microdialysis and population pharmacokinetic modelling. J Antimicrob Chemother 2019; 74:1975-1983. [DOI: 10.1093/jac/dkz139] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/04/2019] [Accepted: 03/07/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Cefoxitin is frequently used for surgical antibiotic prophylaxis (SAP). Using microdialysis, we evaluated whether the currently recommended dosing regimen is appropriate to maintain cefoxitin subcutaneous tissue concentrations above the MIC for pathogens involved in abdominal surgical site infection.
Methods
Data from eight patients undergoing major abdominal surgery were analysed using population pharmacokinetic modelling, and Monte Carlo simulations were conducted to determine the PTA for aerobic and anaerobic pathogens. ClinicalTrials.gov: NCT02703857.
Results
Only 2.3% and 47.4% of the simulated patients maintained cefoxitin subcutaneous concentrations above the MIC breakpoint for anaerobic (MIC = 16 mg/L) and aerobic (MIC = 8 mg/L) pathogens, respectively. New simulations with administration of a loading dose followed by a constant infusion of cefoxitin were conducted and demonstrate that, notwithstanding using the same total dose per unit of time, continuous infusion of cefoxitin can cover aerobes in 96.6% of the simulated patients, but remains insufficient for anaerobic bacteria.
Conclusions
The recommended dosing regimen of cefoxitin is insufficient for covering the usual bacteria during abdominal surgery. Administration of a loading dose followed by a constant infusion should be considered for aerobic bacteria and cefoxitin should be avoided as SAP for anaerobic bacteria.
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Affiliation(s)
- Matthieu Boisson
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- Département d’Anesthésie-Réanimation, CHU de Poitiers, 2 rue de la milétrie, Poitiers, France
| | - Bruna Gaelzer Silva Torres
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
| | - Sabrina Yani
- Département d’Anesthésie-Réanimation, CHU de Poitiers, 2 rue de la milétrie, Poitiers, France
| | - William Couet
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- Service de Toxicologie-Pharmacocinétique, CHU de Poitiers, 2 rue de la milétrie, Poitiers, France
| | - Olivier Mimoz
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- Service des Urgences & SAMU 86 - Centre 15, CHU de Poitiers, 2 rue de la milétrie, Poitiers, France
| | - Claire Dahyot-Fizelier
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- Département d’Anesthésie-Réanimation, CHU de Poitiers, 2 rue de la milétrie, Poitiers, France
| | - Sandrine Marchand
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- Service de Toxicologie-Pharmacocinétique, CHU de Poitiers, 2 rue de la milétrie, Poitiers, France
| | - Nicolas Grégoire
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- Service de Toxicologie-Pharmacocinétique, CHU de Poitiers, 2 rue de la milétrie, Poitiers, France
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13
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Naik BI, Roger C, Ikeda K, Todorovic MS, Wallis SC, Lipman J, Roberts JA. Comparative total and unbound pharmacokinetics of cefazolin administered by bolus versus continuous infusion in patients undergoing major surgery: a randomized controlled trial. Br J Anaesth 2018; 118:876-882. [PMID: 28505360 DOI: 10.1093/bja/aex026] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2017] [Indexed: 01/04/2023] Open
Abstract
Background. Perioperative administration of cefazolin reduces the incidence of perioperative infections. Intraoperative re-dosing of cefazolin is commonly given between 2 and 5 h after the initial dose. This study was undertaken to determine whether intraoperative continuous infusions of cefazolin achieve better probability of target attainment (PTA) and fractional target attainment (FTA) than intermittent dosing. Methods. Patients undergoing major surgery received cefazolin 2 g before surgical incision. They were subsequently randomized to receive either an intermittent bolus (2 g every 4 h) or continuous infusion (500 mg h -1 ) of cefazolin until skin closure. Blood samples were analysed for total and unbound cefazolin concentrations using a validated chromatographic method. Population pharmacokinetic modelling was performed using Pmetrics ® software. Calculations of PTA and FTA were performed for common pathogens. Results. Ten patients were enrolled in each arm. A two-compartment linear model best described the time course of the total plasma cefazolin concentrations. The covariates that improved the model were body weight and creatinine clearance. Protein binding varied with time [mean (range) 69 (44-80)%] with a fixed 21% unbound value of cefazolin used for the simulations (120 min post-initial dosing). Mean ( sd ) central volume of distribution was 5.73 (2.42) litres, and total cefazolin clearance was 4.72 (1.1) litres h -1 . Continuous infusions of cefazolin consistently achieved better drug exposures and FTA for different weight and creatinine clearances, particularly for less susceptible pathogens. Conclusions. Our study demonstrates that intraoperative continuous infusions of cefazolin increase the achievement of target plasma concentrations, even with lower infusion doses. Renal function and body weight are important when considering the need for alternative dosing regimens. Clinical trial registration. NCT02058979.
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Affiliation(s)
- B I Naik
- Department of Anesthesiology, PO Box 800710, Charlottesville, VA, 22908, USA.,Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - C Roger
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - K Ikeda
- Department of Anesthesiology, PO Box 800710, Charlottesville, VA, 22908, USA
| | - M S Todorovic
- Department of Anesthesiology, Washington University, St Louis, MO, USA
| | - S C Wallis
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - J Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Department of Intensive Care Medicine
| | - J A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital.,Centre for Translational Anti-infective Pharmacodynamics, The University of Queensland, Brisbane, Queensland, Australia
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14
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Pharmacodynamic model for β-lactam regimens used in surgical prophylaxis: model-based evaluation of standard dosing regimens. Int J Clin Pharm 2018; 40:1059-1071. [PMID: 30117081 DOI: 10.1007/s11096-018-0720-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
Background Continual evolution of resistance among bacteria against methods of surgical prophylaxis may make currently used beta-lactam regimens inadequate. Objective To re-evaluate beta-lactam regimens in surgical prophylaxis. Setting A pharmacodynamic Monte Carlo simulation (MCS) model based on a number of patients in China. Methods Pharmacodynamic profiling using Monte Carlo simulation up to 4 hours postinfusion was conducted for standard-dose, short-term (0.5 h) and prolonged (2 to 4 h) infusions of ampicillin, cefazolin, cefotaxime, cefoxitin, cefuroxime, ertapenem, and piperacillin/tazobactam in adult patients with normal renal function. Microbiological data were incorporated. Cumulative fraction of response (CFR) was determined for each regimen against populations of S. aureus, coagulase-negative staphylococci and E. coli. The optimal CFR was defined as ≥ 90% response. Main Outcome Measure Cumulative fractions of response of pharmacodynamic target attainment. Results During the first 2 hours postinfusion, piperacillin/tazobactam 3.375 g exhibited consistently optimal cumulative fractions against S. aureus, CoNS and E. coli. Ampicillin 2 g (2 h) also displayed optimal CFRs for S. aureus and E. coli but not for coagulase-negative staphylococci. Cefoxitin 2 g didnot achieve any optimal CFRs, even via 2-h prolonged infusion (maximum 72.8% CFR for S. aureus and 64.5% CFR for E. coli). Cefazolin 2 g (4 h) and cefuroxime 1.5 g (4 h) provided desired CFRs across 4 h postinfusion for S. aureus but provided poor CFRs for coagulase-negative staphylococci and E. coli. Only ertapenem 1 g for E. coli and S. aureus and cefotaxime 1 g for E. coli consistently yielded ≥ 90% CFRs for 4 hour postinfusion. Conclusions Certain dosing regimens may warrant adjustment for improved prevention efficiency and enhanced empirical antibiotic regimens for surgical prophylaxis.
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15
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Ozoya OO, Siegel EM, Srikumar T, Bloomer AM, DeRenzis A, Shibata D. Quantitative Assessment of Visceral Obesity and Postoperative Colon Cancer Outcomes. J Gastrointest Surg 2017; 21:534-542. [PMID: 28101721 PMCID: PMC5560865 DOI: 10.1007/s11605-017-3362-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/04/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quantitative computed tomography (CT) assessment of visceral adiposity may be superior to body mass index (BMI) as a predictor of surgical morbidity. We sought to examine the association of CT measures of obesity and BMI with short-term postoperative outcomes in colon cancer patients. METHODS In this retrospective study, 110 patients treated with colectomy for stage I-III colon cancer were classified as obese or non-obese by preoperative CT-based measures of adiposity or BMI [obese: BMI ≥ 30 kg/m2, visceral fat area (VFA) to subcutaneous fat area ratio (V/S) ≥0.4, and VFA > 100 cm2]. Postoperative morbidity and mortality rates were compared. RESULTS Obese patients, by V/S and VFA but not BMI, were more likely to be male and have preexisting hypertension and diabetes. The overall complication rate was 25.5%, and there were no mortalities. Obese patients by VFA (with a trend for V/S but not BMI) were more likely to develop postoperative complications as compared to patients classified as non-obese: VFA (30.5 vs.10.7%, p = 0.03), V/S (29.2 vs. 9.5%, p = 0.05), and BMI (32.4 vs. 21.9%, p = 0.23). CONCLUSIONS Elevated visceral obesity quantified by CT is associated with the presence of key metabolic comorbidities and increased postoperative morbidity and may be superior to BMI for risk stratification.
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Affiliation(s)
- Oluwatobi. O. Ozoya
- Cancer Epidemiology, Moffitt Cancer Center, Tampa FL,Department of Global Health, College of Public Health, University of
South Florida, Tampa, FL
| | - Erin M. Siegel
- Cancer Epidemiology, Moffitt Cancer Center, Tampa FL,Health Research Informatics, Moffitt Cancer Center, Tampa, FL
| | - Thejal Srikumar
- Cancer Epidemiology, Moffitt Cancer Center, Tampa FL,Morsani College of Medicine, University of South Florida, Tampa,
FL
| | | | | | - David Shibata
- Department of Surgery, UT West Cancer Center, University of
Tennessee Health Science Center, Memphis, TN
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16
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Pharmacokinetic and Pharmacodynamic Evaluation of a Weight-Based Dosing Regimen of Cefoxitin for Perioperative Surgical Prophylaxis in Obese and Morbidly Obese Patients. Antimicrob Agents Chemother 2016; 60:5885-93. [PMID: 27458209 DOI: 10.1128/aac.00585-16] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/22/2016] [Indexed: 11/20/2022] Open
Abstract
The objective of this study was to determine the pharmacokinetics and pharmacodynamics (PK/PD) of a weight-based cefoxitin dosing regimen for surgical prophylaxis in obese patients. Patients received a single dose of cefoxitin at 40 mg/kg based on total body weight. Cefoxitin samples were obtained over 3 h from serum and adipose tissue, and concentrations were determined by validated high-performance liquid chromatography. Noncompartmental pharmacokinetic analysis was performed, followed by Monte Carlo simulations to estimate probability of target attainment (PTA) for Staphylococcus aureus, Escherichia coli, and Bacteroides fragilis over 4-h periods postdose. Thirty patients undergoing bariatric procedures were enrolled. The body mass index (mean ± standard deviation [SD])was 45.9 ± 8.0 kg/m(2) (range, 35.0 to 76.7 kg/m(2)); the median cefoxitin dose was 5 g (range, 4.0 to 7.5 g). The mean maximum concentrations were 216.15 ± 41.80 μg/ml in serum and 12.62 ± 5.89 in tissue; the mean tissue/serum ratio was 8% ± 3%. In serum, weight-based regimens achieved ≥90% PTA (goal time during which free [unbound] drug concentrations exceed pathogen MICs [fT>MIC] of 100%) for E. coli and S. aureus over 2 h and for B. fragilis over 1 h; in tissue this regimen failed to achieve goal PTA at any time point. The 40-mg/kg regimens achieved higher PTAs over longer periods in both serum and tissue than did the standard 2-g doses. However, although weight-based cefoxitin regimens were better than fixed doses, achievement of desired pharmacodynamic targets was suboptimal in both serum and tissue. Alternative dosing regimens and agents should be explored in order to achieve more favorable antibiotic performance during surgical prophylaxis in obese patients.
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17
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Zelenitsky SA, Lawson C, Calic D, Ariano RE, Roberts JA, Lipman J, Zhanel GG. Integrated pharmacokinetic-pharmacodynamic modelling to evaluate antimicrobial prophylaxis in abdominal surgery. J Antimicrob Chemother 2016; 71:2902-8. [PMID: 27402005 DOI: 10.1093/jac/dkw247] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/20/2016] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To use Monte Carlo simulation with an integrated pharmacokinetic-pharmacodynamic (PK-PD) model to evaluate guideline-recommended antimicrobial prophylaxis (AP) regimens with anaerobic coverage in abdominal surgery. METHODS AP regimens were tested in simulated subjects undergoing elective abdominal surgery using relevant PK models and pathogen distributions in surgical site infections (SSIs). Predicted cumulative target attainment was the percentage of simulated subjects with free (unbound) antimicrobial plasma concentrations above the MICs for potential SSI pathogens. RESULTS Cefazolin plus metronidazole covered SSI aerobes in 70% and the Bacteroides fragilis group in 99% of subjects, whereas cefoxitin only covered aerobes and anaerobes in 63% and 27% of cases, respectively. The broad-spectrum ceftriaxone plus metronidazole covered aerobes in 82% and anaerobes in 99% of simulations, while ertapenem covered aerobes in 88% and anaerobes in 90% of cases. Clindamycin covered the B. fragilis group in only 11% of cases. For cefazolin, 2 g doses maintained target attainment in simulated subjects from 80 to 120 kg, whereas 1 g doses were associated with lower target attainment against potential Gram-negative pathogens even in those <80 kg. For gentamicin, 3 mg/kg doses were comparable to the suggested 5 mg/kg, but superior to the traditional 1.5 mg/kg. CONCLUSIONS This study demonstrates the use of PK-PD to inform decisions regarding AP in abdominal surgery. In this case, the findings support avoiding cefoxitin, avoiding clindamycin for anaerobic coverage, selecting 2 g doses of cefazolin even in patients <80 kg and using 3 mg/kg doses of gentamicin.
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Affiliation(s)
- S A Zelenitsky
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada Department of Pharmacy, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - C Lawson
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - D Calic
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - R E Ariano
- College of Pharmacy, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada Department of Pharmacy, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - J A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - J Lipman
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia Australia Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia The University of Witwatersrand, Johannesburg, South Africa
| | - G G Zhanel
- Department of Medical Microbiology and Infectious Diseases, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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18
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Brunetti L, Kagan L, Forrester G, Aleksunes LM, Lin H, Buyske S, Nahass RG. Cefoxitin Plasma and Subcutaneous Adipose Tissue Concentration in Patients Undergoing Sleeve Gastrectomy. Clin Ther 2016; 38:204-10. [PMID: 26686826 PMCID: PMC4715936 DOI: 10.1016/j.clinthera.2015.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/14/2015] [Accepted: 11/12/2015] [Indexed: 01/21/2023]
Abstract
PURPOSE Antibiotic dosing in obese surgical patients has not been adequately evaluated. The objective of this study was to identify whether currently prescribed doses of cefoxitin achieve adequate and sustained plasma and tissue concentrations in obese patients undergoing sleeve gastrectomy. METHODS A prospective evaluation of plasma and tissue cefoxitin concentrations in patients undergoing sleeve gastrectomy was performed. On the day of the surgical procedure, venous blood samples (5 mL) were collected just before cefoxitin administration and then at 5, 30, 60, 120, and 240 minutes after dose administration. In addition, subcutaneous adipose tissue was collected from the surgical site at the time of surgical incision and at closure. Cefoxitin concentrations in the collected samples were quantified by using an HPLC-ultraviolet method. A standard noncompartmental analysis was performed for each individual cefoxitin plasma concentration-time profile. In addition, the ratio of tissue to plasma concentration was calculated for all patients. FINDINGS Plasma and tissue pharmacokinetics of cefoxitin were evaluated in 6 patients undergoing sleeve gastrectomy. The mean age and BMI were 48.7 (6.2) years and 42.8 (7.1) kg/m(2), respectively. At the time of surgical closure, subcutaneous adipose tissue concentrations of cefoxitin were subtherapeutic (<8 µg/mL) in all evaluated patients. IMPLICATIONS Current dosing strategies for cefoxitin in obese surgical patients may be inadequate, and there is an urgent need to define the appropriate dosage.
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Affiliation(s)
- Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey.
| | - Leonid Kagan
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey
| | | | - Lauren M Aleksunes
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, New Jersey
| | - Hongxia Lin
- Pharmacokinetic/Pharmacodynamic Shared Resource, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Steven Buyske
- Department of Statistics and Biostatistics, Rutgers, The State University of New Jersey, Piscataway, New Jersey
| | - Ronald G Nahass
- ID Care, Hillsborough and Robert Wood Johnson University Hospital Somerset, Somerville, New Jersey
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19
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Canut A, Isla A, Rodríguez-Gascón A. Pharmacokinetic/pharmacodynamic analysis to evaluate ceftaroline fosamil dosing regimens for the treatment of community-acquired bacterial pneumonia and complicated skin and skin-structure infections in patients with normal and impaired renal function. Int J Antimicrob Agents 2015; 45:399-405. [PMID: 25700566 DOI: 10.1016/j.ijantimicag.2014.12.023] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 12/12/2014] [Accepted: 12/16/2014] [Indexed: 11/27/2022]
Abstract
In this study, the probability of pharmacokinetic/pharmacodynamic target attainment (PTA) of ceftaroline against clinical isolates causing community-acquired bacterial pneumonia (CABP) and complicated skin and skin-structure infection (cSSSI) in Europe was evaluated. Three dosing regimens were assessed: 600 mg every 12 h (q12 h) as a 1-h infusion (standard dose) or 600 mg every 8 h (q8 h) as a 2-h infusion in virtual patients with normal renal function; and 400 mg q12 h as a 1-h infusion in patients with moderate renal impairment. Pharmacokinetic and microbiological data were obtained from the literature. The PTA and the cumulative fraction of response (CFR) were calculated by Monte Carlo simulation. In patients with normal renal function, the ceftaroline standard dose (600 mg q12 h as a 1-h infusion) can be sufficient to treat CABP due to ceftazidime-susceptible (CAZ-S) Escherichia coli, CAZ-S Klebsiella pneumoniae, meticillin-susceptible Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis (CFR>90%). However, against meticillin-resistant S. aureus (MRSA), the CFR was 72%. In cSSSI, the CFR was also <80% for MRSA. Administration of ceftaroline 600 mg q8 h as a 2-h infusion or 400 mg q12 h as a 1-h infusion in patients with moderate renal insufficiency provided a high probability of treatment success (CFR ca. 100%) for most micro-organisms causing CABP and cSSSI, including MRSA and penicillin-non-susceptible S. pneumoniae. These results suggest that in patients with normal renal function, ceftaroline 600 mg q8 h as a 2-h infusion may be a better option than the standard dose, especially if the MRSA rate is high.
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Affiliation(s)
- A Canut
- Microbiology Service, Hospital Universitario de Álava, Servicio Vasco de Salud Osakidetza, Vitoria-Gasteiz, Spain; Instituto de Investigación Sanitaria de Álava (BIOARABA), Servicio Vasco de Salud Osakidetza, Vitoria-Gasteiz, Spain
| | - A Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - A Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain.
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Gordon RJ. Administration of Parenteral Prophylactic Beta-Lactam Antibiotics in 2014. Anesth Analg 2015; 120:877-87. [DOI: 10.1213/ane.0000000000000468] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Asín-Prieto E, Rodríguez-Gascón A, Isla A. Applications of the pharmacokinetic/pharmacodynamic (PK/PD) analysis of antimicrobial agents. J Infect Chemother 2015; 21:319-29. [PMID: 25737147 DOI: 10.1016/j.jiac.2015.02.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/20/2015] [Accepted: 02/02/2015] [Indexed: 12/15/2022]
Abstract
The alarming increase of resistance against multiple currently available antibiotics is leading to a rapid lose of treatment options against infectious diseases. Since the antibiotic resistance is partially due to a misuse or abuse of the antibiotics, this situation can be reverted when improving their use. One strategy is the optimization of the antimicrobial dosing regimens. In fact, inappropriate drug choice and suboptimal dosing are two major factors that should be considered because they lead to the emergence of drug resistance and consequently, poorer clinical outcomes. Pharmacokinetic/pharmacodynamic (PK/PD) analysis in combination with Monte Carlo simulation allows to optimize dosing regimens of the antibiotic agents in order to conserve their therapeutic value. Therefore, the aim of this review is to explain the basis of the PK/PD analysis and associated techniques, and provide a brief revision of the applications of PK/PD analysis from a therapeutic point-of-view. The establishment and reevaluation of clinical breakpoints is the sticking point in antibiotic therapy as the clinical use of the antibiotics depends on them. Two methodologies are described to establish the PK/PD breakpoints, which are a big part of the clinical breakpoint setting machine. Furthermore, the main subpopulations of patients with altered characteristics that can condition the PK/PD behavior (such as critically ill, elderly, pediatric or obese patients) and therefore, the outcome of the antibiotic therapy, are reviewed. Finally, some recommendations are provided from a PK/PD point of view to enhance the efficacy of prophylaxis protocols used in surgery.
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Affiliation(s)
- Eduardo Asín-Prieto
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group (PharmaNanoGene), Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain; Centro de Investigación Lascaray ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain.
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Pharmacological study of cefoxitin as an alternative antibiotic therapy to carbapenems in treatment of urinary tract infections due to extended-spectrum-β-lactamase-producing Escherichia coli. Antimicrob Agents Chemother 2014; 58:4899-901. [PMID: 24777104 DOI: 10.1128/aac.02509-14] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Cefoxitin could be an alternative to carbapenems in extended-spectrum-beta-lactamase-producing Escherichia coli (ESBL-EC) infections. However, pharmacological and clinical data regarding cefoxitin are limited. Using a recent pharmacological model and the MICs of ESBL-EC collected from pyelonephritis, we determined the probabilities to reach four pharmacological targets: free cefoxitin concentrations above the MIC during 50% and 100% of the administration interval (T>MIC = 50% and T>MIC = 100%, respectively) and free cefoxitin concentrations above 4× MIC during 50% and 100% of the administration interval (T>4MIC = 50% and T>4MIC = 100%, respectively). Cefoxitin could be used to treat ESBL-EC pyelonephritis, but administration modalities should be optimized according to MICs in order to reach pharmacological targets.
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Moine P, Fish DN. Pharmacodynamic modelling of intravenous antibiotic prophylaxis in elective colorectal surgery. Int J Antimicrob Agents 2012. [PMID: 23182539 DOI: 10.1016/j.ijantimicag.2012.09.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical-site infections are the leading cause of post-operative morbidity and mortality as well as increased costs following colorectal surgery. The purpose of this study was to evaluate different β-lactam antimicrobial dosing regimens currently used for prophylaxis in elective colorectal procedures with the aim of identifying optimal antibiotics and dosing regimens. Serum pharmacokinetic (PK) parameters specific to each drug for use in pharmacodynamic (PD) modelling were obtained from the published literature. Susceptibility data for Escherichia coli, Bacteroides fragilis and Staphylococcus aureus for use in modelling simulations were obtained from the European Committee on Antimicrobial Susceptibility Testing (EUCAST). Monte Carlo simulation was used to evaluate the influence of dose and dosing frequency of tested antibiotics to achieve a prophylaxis target fT>MIC (time during which the free drug concentration exceeds the pathogen minimum inhibitory concentration) of 100% for up to 4h. Ertapenem 1g, cefuroxime 1.5 g and cefazolin 2 g were the only antibiotic regimens that consistently yielded target fT>MIC of 100% for the entire 4-h post-dose interval and against all targeted organisms more than 90% of the time. In contrast, cefoxitin, cefotetan and ampicillin/sulbactam yielded very poor predicted PK/PD performances. In conclusion, this study demonstrates the value of, and need for, applied PD research in the area of surgical prophylaxis. Whether cefoxitin, cefotetan or ampicillin/sulbactam should continue to be advocated as first-line agents for prophylaxis during elective colorectal surgery, particularly at the standard doses currently being used, is debatable.
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Affiliation(s)
- P Moine
- University of Colorado Denver, School of Medicine, Department of Anesthesiology, Mail Stop B113, 12401 East 17th Avenue, Aurora, CO 80045, USA.
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