Experience with daptomycin daily dosing in ICU patients undergoing continuous renal replacement therapy

Rapid Aggravation of Rhabdomyolysis Caused by Daptomycin After Aortic Arch Replacement: A Case Report

Although rare, rhabdomyolysis is a serious complication of cardiothoracic surgery. Daptomycin is a polypeptide antimicrobial agent used to treat methicillin-resistant Staphylococcus aureus (MRSA) infections of the soft tissues. Daptomycin is associated with elevations in serum creatine kinase (CK). A 50-year-old man with acute Stanford A-type aortic dissection was performed Bentall procedure and total arch replacement with frozen elephant trunk. The CK level was 6,573 U/L on the first postoperative day (POD), suggesting rhabdomyolysis associated with lower limb ischemia. The CK level increased to 11,934 U/L on POD 2 and started to decrease thereafter. On POD 5, the patient had a suspected surgical site infection. Antibiotics were changed to empiric therapy of daptomycin and meropenem to address soft tissue MRSA infection. The CK level at the start of daptomycin administration was 4,122 U/L. However, the CK level rose to 21,813 U/L on POD 6. None of the findings suggested new-onset lower limb ischemia. Assuming that the rhabdomyolysis was induced by daptomycin, it was discontinued. The CK level peaked at 26,123 U/L on POD 8, after which it started to decrease and normalized on POD 16. Daptomycin should be used with extreme caution in patients recovering from rhabdomyolysis.

Optimal antipseudomonal ꞵ-lactam drug dosing recommendations in critically-ill Asian patients receiving CRRT

INTRODUCTION

The average body weight is smaller in Asian patients compared with Western patients, but influence of body weight in antibiotic dosing is unknown. This study was to predict the optimal ceftazidime, cefepime, meropenem, piperacillin/tazobactam doses in Asian patients undergoing continuous venovenous hemofiltration (CVVH).

METHODS

Monte Carlo simulations (MCS) were performed using published Asian demographics and pharmacokinetics parameters in 5000 virtual patients at three CVVH effluent rates (Qeff; 20, 30, 40 mL/kg/h). Various dosing regimens were assessed for the probability of target attainments using 60% fT > 1 × MIC or 4xMIC and neurotoxicity risk at 48-h using suggested neurotoxicity thresholds.

RESULTS

Ceftazidime 1 g q12h, meropenem 1 g q12h, and piperacillin/tazobactam 3.375 g q6h were optimal for all Qeff settings against fT > 1 × MIC. Cefepime 2 g q24h and 2 g q12h were optimal at 20 and 30-40 mL/kg/h respectively. For the aggressive PD target (4 × MIC), optimal ceftazidime regimens were 1.25 g q8h (20-30 mL/kg/h) and 1.5 g q8h (40 mL/kg/h). Cefepime 2 g q8h and meropenem 1 g q8h were optimal at all Qeff settings. No simulated piperacillin doses attained the aggressive PD target. Increased neurotoxicity risk was predicted with ceftazidime and cefepime doses attaining the efficacy.

CONCLUSION

MCS enabled the prediction of optimal β-lactam dosing regimens for Asian patients receiving CVVH at varying Qeff. Clinical validation is warranted.

An optimal extended-infusion dosing of cefepime and ceftazidime in critically ill patients with continuous renal replacement therapy

PURPOSE

This study aimed to determine optimal extended-infusion dosing regimens for cefepime and ceftazidime in critically ill patients receiving continuous renal replacement therapy using Monte Carlo Simulations (MCS).

MATERIALS AND METHODS

Pharmacokinetic models were built using published pharmacokinetic/demographic data to predict drug disposition in 5000 virtual critically ill patients receiving continuous venovenous hemofiltration (CVVH) with the standard (20-30 mL/kg/h) and a higher (40 mL/kg/h) effluent rates. MCS was performed to assess the probability of target attainment (PTA) of four cefepime and ceftazidime doses administered over 4-h with the target of ≥60% fT > 4×MIC. The lowest dose attaining PTA ≥90% during the first 48-h was considered optimal. Additionally, risk of drug toxicity was assessed at 48-h using suggested neurotoxicity thresholds.

RESULTS

Cefepime 2 g loading dose (LD), then extended-infusion of 2 g q8hr was optimal in CVVH at 20 mL/kg/h and the same ceftazidime dose was optimal in CVVH at 20-30 mL/kg/h. Higher cefepime and ceftazidime doses were required to be optimal at higher effluent rates. This optimal dose particularly for cefepime likely increases neurotoxicity risk in most virtual patients with all CVVH settings.

CONCLUSIONS

Cefepime and ceftazidime 2 g LD, followed by extended-infusion 2 g q8hr may be optimal in CVVH with standard effluent rates.

Therapeutic Drug Monitoring of Antibiotic Drugs in Patients Receiving Continuous Renal Replacement Therapy or Intermittent Hemodialysis: A Critical Review

PURPOSE

Antibiotics are frequently used in patients receiving intermittent or continuous renal replacement therapy (RRT). Continuous renal replacement may alter the pharmacokinetics (PK) and the ability to achieve PK/pharmacodynamic (PD) targets. Therapeutic drug monitoring (TDM) could help evaluate drug exposure and guide antibiotic dosage adjustment. The present review describes recent TDM data on antibiotic exposure and PK/PD target attainment (TA) in patients receiving intermittent or continuous RRT, proposing practical guidelines for performing TDM.

METHODS

Studies on antibiotic TDM performed in patients receiving intermittent or continuous RRT published between 2000 and 2020 were searched and assessed. The authors focused on studies that reported data on PK/PD TA. TDM recommendations were based on clinically relevant PK/PD relationships and previously published guidelines.

RESULTS

In total, 2383 reports were retrieved. After excluding nonrelevant publications, 139 articles were selected. Overall, 107 studies reported PK/PD TA for 24 agents. Data were available for various intermittent and continuous RRT techniques. The study design, TDM practice, and definition of PK/PD targets were inconsistent across studies. Drug exposure and TA rates were highly variable. TDM seems to be necessary to control drug exposure in patients receiving intermittent and continuous RRT techniques, especially for antibiotics with narrow therapeutic margins and in critically ill patients. Practical recommendations can provide insights on relevant PK/PD targets, sampling, and timing of TDM for various antibiotic classes.

CONCLUSIONS

Highly variable antibiotic exposure and TA have been reported in patients receiving intermittent or continuous RRT. TDM for aminoglycosides, beta-lactams, glycopeptides, linezolid, and colistin is recommended in patients receiving RRT and suggested for daptomycin, fluoroquinolones, and tigecycline in critically ill patients on RRT.

Recommendation of Antimicrobial Dosing Optimization During Continuous Renal Replacement Therapy

Continuous Renal Replacement Therapy (CRRT) is more and more widely used in patients for various indications recent years. It is still intricate for clinicians to decide a suitable empiric antimicrobial dosing for patients receiving CRRT. Inappropriate doses of antimicrobial agents may lead to treatment failure or drug resistance of pathogens. CRRT factors, patient individual conditions and drug pharmacokinetics/pharmacodynamics are the main elements effecting the antimicrobial dosing adjustment. With the development of CRRT techniques, some antimicrobial dosing recommendations in earlier studies were no longer appropriate for clinical use now. Here, we reviewed the literatures involving in new progresses of antimicrobial dosages, and complied the updated empirical dosing strategies based on CRRT modalities and effluent flow rates. The following antimicrobial agents were included for review: flucloxacillin, piperacillin/tazobactam, ceftriaxone, ceftazidime/avibactam, cefepime, ceftolozane/tazobactam, sulbactam, meropenem, imipenem, panipenem, biapenem, ertapenem, doripenem, amikacin, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, azithromycin, tigecycline, polymyxin B, colistin, vancomycin, teicoplanin, linezolid, daptomycin, sulfamethoxazole/trimethoprim, fluconazole, voriconazole, posaconzole, caspofungin, micafungin, amphotericin B, acyclovir, ganciclovir, oseltamivir, and peramivir.

Liquid chromatography-tandem mass spectrometry for the quantification of moxifloxacin, ciprofloxacin, daptomycin, caspofungin, and isavuconazole in human plasma

A simple and precise ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method was developed for the simultaneous analysis of five anti-infective agents used to treat severe infections [three antibiotics (daptomycin, moxifloxacin, ciprofloxacin) and two antifungals (isavuconazole, caspofungin)] in human plasma. Sample preparation was based on protein precipitation with ice cold methanol. All five agents were analyzed with the corresponding isotopically labeled internal standards. All analytes were detected in multiple reactions monitoring (MRM) using API 4000 triple-quadrupole mass spectrometer with electrospray (ESI) source operating in positive mode. The calibration curves were linear over the selected ranges (r > 0.99). The method is precise and accurate with a total run time of 5.5 min. Accuracy of all target analytes ranged between 95.9-116.6%, measured with an imprecision of less than 10.8%. The lower limit of quantification was 1.25 mg/L for caspofungin, 0.3125 mg/L for isavuconazole, 3.125 mg/L for daptomycin, 0.075 mg/L for ciprofloxacin, and 0.1875 mg/L for moxifloxacin. The successful application of the method in patient samples proved its suitability for the medical surveillance of antimicrobial therapy in intensive care units as well as to other pharmacokinetic studies.

Daptomycin Pharmacokinetics and Pharmacodynamics in Septic and Critically Ill Patients

Infections, including sepsis, are associated with high mortality rates in critically ill patients in the intensive care unit (ICU). Appropriate antibiotic selection and adequate dosing are important for improving patient outcomes. Daptomycin is bactericidal in bloodstream infections caused by Staphylococcus aureus and other Gram-positive pathogens cultured in ICU patients. The drug has concentration-dependent activity, and the area under the curve/minimum inhibitory concentration ratio is the pharmacokinetic/pharmacodynamic (PK/PD) index that best correlates with daptomycin activity, whereas toxicity correlates well with daptomycin plasma trough concentrations (or minimum concentration [C min]). Adequate daptomycin exposure can be difficult to achieve in ICU patients; multiple PK alterations can result in highly variable plasma concentrations, which are difficult to predict. For this reason, therapeutic drug monitoring could help clinicians optimize daptomycin dosing, thus improving efficacy while decreasing the likelihood of serious adverse events. This paper reviews the literature on daptomycin in ICU patients with sepsis, focusing on dosing and PK and PD parameters.

Population pharmacokinetics of daptomycin in adult patients undergoing continuous renal replacement therapy

Aim

The objective of this population pharmacokinetic (PK) analysis was to provide guidance for the dosing interval of daptomycin in patients undergoing continuous renal replacement therapy (CRRT).

Methods

A previously published population PK model for daptomycin was updated with data from patients undergoing continuous veno‐venous haemodialysis (CVVHD; n = 9) and continuous veno‐venous haemodiafiltration (CVVHDF; n = 8). Model‐based simulations were performed to compare the 24 h AUC, C_max and C_min of daptomycin following various dosing regimens (4, 6, 8, 10, and 12 mg kg⁻¹ every [Q] 24 h and Q48 h), with the safety and efficacy exposure references for Staphylococcus aureus bacteraemia/right‐sided infective endocarditis.

Results

The previously developed daptomycin structural population PK model could reasonably describe data from the patients on CRRT. The clearance in patients undergoing CVVHDF and CVVHD was estimated at 0.53 and 0.94 l h⁻¹, respectively, as compared with 0.75 l h⁻¹ in patients with creatinine clearance (CrCl) ≥ 30 ml min⁻¹. Daptomycin Q24 h dosing in patients undergoing CRRT resulted in optimal exposure for efficacy, with AUC comparable to that in patients with CrCl ≥ 30 ml min⁻¹. In contrast, Q48 h dosing was associated with considerably lower AUC_24–48h in all patients for doses up to 12 mg kg⁻¹ and is therefore inappropriate.

Conclusions

Q24 h dosing of daptomycin up to 12 mg kg⁻¹ provides comparable drug exposure in patients on CVVHD and in those with CrCl ≥ 30 ml min⁻¹. Daily daptomycin use up to 8 mg kg⁻¹ doses are appropriate for patients on CVVHDF, but higher doses may increase the risk of toxicity.

To increase or decrease dosage of antimicrobials in septic patients during continuous renal replacement therapy: the eternal doubt

Critical illness, acute renal failure and continuous renal replacement therapy (CRRT) are associated with changes in pharmacokinetics. Initial antibiotic dose should be based on published volume of distribution and generally be at least the standard dose, as volume of distribution is usually unchanged or increased. Subsequent doses should be based on total clearance. Total clearance varies with the CRRT clearance which mainly depends on effluent flow rate, sieving coefficient/saturation coefficient. As antibiotic clearance by healthy kidneys is usually higher than clearance by CRRT, except for colistin, subsequent doses should generally be lower than given to patients without renal dysfunction. In the future therapeutic drug monitoring, together with sophisticated pharmacokinetic models taking into account the pharmacokinetic variability, may enable more appropriate individualized dosing.

Intravenous Antibiotics Used in the Treatment of Methicillin-Resistant Staphylococcus Aureus

Methicillin-resistant Staphylococcus aureus (MRSA) continues to cause significant morbidity and mortality. Despite advances in medical care, the prevalence of both community-acquired and hospital-acquired MRSA has progressively increased. Community-acquired MRSA typically occurs in patients without recent illness or hospitalization, presents as acute skin and soft tissue infections, and is usually not multidrug resistant. Hospital-acquired MRSA, however, presents in patients recently hospitalized or treated in long-term care settings and in those who have had medical procedures and is usually associated with multidrug-resistant strains. Both types of infections, if not properly treated, have the potential to become invasive. This article discusses current intravenous antibiotics that are available for the empiric treatment of MRSA infections along with a newer phenomenon known as the "seesaw effect."

Intravenous Antibiotics Used in the Treatment of Methicillin-Resistant Staphylococcus Aureus

Methicillin-resistant Staphylococcus aureus (MRSA) continues to cause significant morbidity and mortality. Despite advances in medical care, the prevalence of both community-acquired and hospital-acquired MRSA has progressively increased. Community-acquired MRSA typically occurs in patients without recent illness or hospitalization, presents as acute skin and soft tissue infections, and is usually not multidrug resistant. Hospital-acquired MRSA, however, presents in patients recently hospitalized or treated in long-term care settings and in those who have had medical procedures and is usually associated with multidrug-resistant strains. Both types of infections, if not properly treated, have the potential to become invasive. This article discusses current intravenous antibiotics that are available for the empiric treatment of MRSA infections along with a newer phenomenon known as the “seesaw effect.”

Pharmacokinetics of daily daptomycin in critically ill patients undergoing continuous renal replacement therapy

BACKGROUND

The optimal daptomycin dosing regimen for critically ill patients undergoing continuous renal replacement therapy (CRRT) has still to be established.

METHODS

Daptomycin pharmacokinetics was determined in 9 patients after administration of 6 mg/kg/day over 5 days.

RESULTS

At steady state, which was reached by day 3, the area under the curve over 24 h (AUC24h) was 667.4 ± 356.6 mg·h/l, and the maximum concentration (Cmax) was 66.9 ±25.3 mg/l. Mean CRRT clearance accounted for 48% (range 32-67%) of total clearance (mean 10.2 ml/min, range 6.1-18 ml/min). Significant correlations were observed between Cmax, minimum concentration (Cmin) and AUC24h (R(2) = 0.91, p < 0.001, and R(2) = 0.94, p < 0.001) and between albumin plasma concentration and free daptomycin (R(2) = 0.7, p = 0.009).

CONCLUSION

No significant accumulation occurred with a daily daptomycin dose of 6 mg/kg in patients undergoing CRRT with an effluent flow rate of >30 ml/kg/h. The quantification of trough concentrations (Cmin) appears to be a good surrogate to estimate AUC24h and to monitor daptomycin treatment in patients undergoing CRRT.