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Dyett BP, Sarkar S, Yu H, Strachan J, Drummond CJ, Conn CE. Overcoming Therapeutic Challenges of Antibiotic Delivery with Cubosome Lipid Nanocarriers. ACS APPLIED MATERIALS & INTERFACES 2024. [PMID: 38690584 DOI: 10.1021/acsami.4c00921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Low discovery rates for new antibiotics, commercial disincentives to invest, and inappropriate use of existing drugs have created a perfect storm of antimicrobial resistance (AMR). This "silent pandemic" of AMR looms as an immense, global threat to human health. In tandem, many potential novel drug candidates are not progressed due to elevated hydrophobicity, which may result in poor intracellular internalization and undesirable serum protein binding. With a reducing arsenal of effective antibiotics, enabling technology platforms that improve the outcome of treatments, such as repurposing existing bioactive agents, is a prospective option. Nanocarrier (NC) mediated drug delivery is one avenue for amplifying the therapeutic outcome. Here, the performance of several antibiotic classes encapsulated within the lipid-based cubosomes is examined. The findings demonstrate that encapsulation affords significant improvements in drug concentration:inhibition outcomes and assists in other therapeutic challenges associated with internalization, enzyme degradation, and protein binding. We emphasize that a currently sidelined compound, novobiocin, became active and revealed a significant increase in inhibition against the pathogenic Gram-negative strain, Pseudomonas aeruginosa. Encapsulation affords co-delivery of multiple bioactives as a strategy for mitigating failure of monotherapies and tackling resistance. The rationale in optimized drug selection and nanocarrier choice is examined by transport modeling which agrees with experimental inhibition results. The results demonstrate that lipid nanocarrier encapsulation may alleviate a range of challenges faced by antibiotic therapies and increase the range of antibiotics available to treat bacterial infections.
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Affiliation(s)
- Brendan P Dyett
- School of Science, STEM College, RMIT University, Melbourne, Victoria 3001, Australia
| | - Sampa Sarkar
- School of Science, STEM College, RMIT University, Melbourne, Victoria 3001, Australia
| | - Haitao Yu
- School of Science, STEM College, RMIT University, Melbourne, Victoria 3001, Australia
| | - Jamie Strachan
- School of Science, STEM College, RMIT University, Melbourne, Victoria 3001, Australia
| | - Calum J Drummond
- School of Science, STEM College, RMIT University, Melbourne, Victoria 3001, Australia
| | - Charlotte E Conn
- School of Science, STEM College, RMIT University, Melbourne, Victoria 3001, Australia
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Ragonnet G, Guilhaumou R, Hanafia O, Néant N, Denante S, Vanel N, Honoré S, Michel F. Continuous infusion of beta-lactam antibiotics in pediatric intensive care unit: A monocenter before/after implementation study. Anaesth Crit Care Pain Med 2024; 43:101354. [PMID: 38360404 DOI: 10.1016/j.accpm.2024.101354] [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: 09/16/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 02/17/2024]
Abstract
CONTEXT Beta-lactam continuous infusion (CI) is currently recommended in adult intensive care units to achieve target concentrations. In pediatric intensive care (PICU), few studies suggest the value of Beta-lactam CI to achieve target concentration. Our objective was to analyze the impact of Beta-lactam CI protocolization on the achievement of target concentration in PICU patients. MATERIAL AND METHODS We conducted a single-center retrospective study in patients with beta-lactam treatment for more than 2 days and at least one sample for therapeutic drug monitoring (TDM). From January 2018 to February 2022 (period 1, P1), BL were administered as an intermittent infusion with TDM upon request. From February to September 2022 (period 2, P2), Beta-lactam CI with TDM at day one was protocolized. The primary endpoint concerned achieving fT>4× Minimum Inhibitory Concentration = 100%. RESULTS In P1, 214 assays involved 103 patients; in P2, 199 assays involved 72 patients. Target concentration achievement was more frequent in P2 (P2 = 73.7% vs. P1 = 29.1%; p < 0.001). At day 5/6 after Beta-lactam initiation, c-reactive protein concentrations were P1 = 84.9 ± 79.2 mg/L; P2 = 53.7±49.8 mg/L (p < 0.05). In the multivariable logistic regression model: P2, BSA, and albumin were positively associated with target achievement; urea, and male sex were negatively associated with target achievement. The daily average cost of beta-lactam vial consumption per child was: P1 = 5.04 ± 2.6 € vs. P2 = 3.21 ± 2.7 € (p-value < 0.001). The daily average reconstitution time of Beta-lactam syringes per child was: P1 = 23.5 ± 8.7 min, P2 = 13.9 ± 9.2 min (p-value < 0.001). CONCLUSION Protocolization of Beta-lactam continuous infusion was associated with more frequent target concentration achievements in PICU. This implementation could be cost-effective and nurse time-saving.
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Affiliation(s)
- Gwendoline Ragonnet
- Pharmacie à Usage Intérieur Centre Hospitalo-Universitaire Timone, 13385 Marseille Cedex 5, France.
| | - Romain Guilhaumou
- Aix Marseille Univ, APHM, Institut des Neurosciences des Systèmes, Inserm UMR 11600, Service de Pharmacologie Clinique et PharmaSurveillance, 13385 Marseille Cedex 5, France
| | - Omar Hanafia
- Pharmacie à Usage Intérieur Centre Hospitalo-Universitaire Timone, 13385 Marseille Cedex 5, France
| | - Nadège Néant
- Laboratoire de Pharmacocinétique et Toxicologie, 13385 Marseille Cedex 5, France
| | - Solène Denante
- Réanimation Pédiatrique Centre Hospitalo-universitaire Timone, 13385 Marseille Cedex 5, France
| | - Noémie Vanel
- Réanimation Pédiatrique Centre Hospitalo-universitaire Timone, 13385 Marseille Cedex 5, France
| | - Stéphane Honoré
- Pharmacie à Usage Intérieur Centre Hospitalo-Universitaire Timone, 13385 Marseille Cedex 5, France; Aix Marseille Univ, EA 3279, CEReSS, Research Centre on Health Services and Quality of Life, Observatoire des Médicaments, Dispositifs Médicaux et Innovations Thérapeutiques (OMéDIT PACA Corse), Marseille, France
| | - Fabrice Michel
- Réanimation Pédiatrique Centre Hospitalo-universitaire Timone, 13385 Marseille Cedex 5, France
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Jenkins A, Jamieson C, Santillo M. Systematic review of room temperature stability of key beta-lactam antibiotics for extended infusions in inpatient settings. Eur J Hosp Pharm 2023; 31:2-9. [PMID: 37848286 PMCID: PMC11148869 DOI: 10.1136/ejhpharm-2023-003855] [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: 05/24/2023] [Accepted: 09/26/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Extended infusion (EI) of beta-lactam antibiotics may offer clinical benefits aligned with improved probability of target attainment for critical pharmacokinetic/pharmacodynamic parameters that correlate with efficacy. There is much research interest in prolonged and continuous infusions (collectively, extended infusions) of beta-lactams to improve patient outcomes, particularly in critically ill patients in intensive care. While definitive clinical trial data demonstrating beneficial outcomes is awaited, there has been limited focus on the stability of the agents given by EI, which may be an equally critical parameter. EI may allow for savings in nursing time due to reduced need for drug reconstitution. We set out to examine the data for stability for EI at room temperature, consistent with the requirements of 'A Standard Protocol for Deriving and Assessment of Stability- Part 1 Aseptic Preparation (Small Molecules)', which allows a 5% loss of active pharmaceutical ingredient (API) applicable for those territories that use the British Pharmacopoeia also for a 10% loss applicable in much of rest of the world. METHODS Searches using preferred reporting items for systematic reviews and meta-analyses (PRISMA) principles for stability data on freshly prepared beta-lactam antimicrobials for extended administration at room temperature (at or above 23°C) were conducted in November 2021 and updated in December 2022. RESULTS We found data to support the extension of the shelf life of 12 key beta-lactam antibiotics once reconstituted (aztreonam, amoxicillin, benzylpenicillin, flucloxacillin, piperacillin/tazobactam, cefazolin, cefmetazole, ceftaroline, ceftazidime, ceftriaxone, imipenem and meropenem) compliant with the NHS protocol, and data for five other agents (ticarcillin, cefepime, cefiderocol, cefoxitin and doripenem) which would be acceptable in regions outside the UK beyond that listed in the Summary of Product Characteristics.This review has not been registered under PROSPERO.
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Affiliation(s)
- Abi Jenkins
- Pharmacy, University Hospitals Birmingham, Birmingham, UK
| | | | - Mark Santillo
- UK and University Hospitals Bristol and Weston NHS Trust, Plymouth Bristol, UK
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Bavaro DF, Belati A, Diella L, Frallonardo L, Guido G, Papagni R, Pellegrino C, Brindicci G, De Gennaro N, Di Gennaro F, Denicolò S, Ronga L, Mosca A, Pomarico F, Dell'Aera M, Stufano M, Dalfino L, Grasso S, Saracino A. Loading dose plus continuous/extended infusion versus intermittent bolus of β-lactams for the treatment of Gram-negative bacteria bloodstream infections: a propensity score-adjusted retrospective cohort study. J Antimicrob Chemother 2023; 78:2175-2184. [PMID: 37428015 DOI: 10.1093/jac/dkad215] [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: 01/24/2023] [Accepted: 06/23/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Optimal β-lactam dosing for the treatment of Gram-negative bacteria bloodstream infections (GNB-BSIs) remains a debated issue. Herein, the efficacy and safety of a loading dose (LD) followed by extended/continuous infusion (EI/CI) versus intermittent bolus (IB) of these drugs for the treatment of GNB-BSIs was evaluated. METHODS This is a retrospective observational study enrolling patients with GNB-BSIs treated with β-lactams from 1 October 2020 to 31 March 2022. The 30 day infection-related mortality rate was assessed with Cox regression, while mortality risk reduction was evaluated by an inverse probability of treatment weighting regression adjustment (IPTW-RA) model. RESULTS Overall, 224 patients were enrolled: 140 and 84 in the IB and EI/CI groups, respectively. β-Lactam regimens were chosen according to pathogen antibiogram, clinical judgement and current guidelines. Interestingly, the LD + EI/CI regimen was associated with a significant lower mortality rate (17% versus 32%, P = 0.011). Similarly, β-lactam LD + EI/CI was significantly associated with a reduced risk of mortality at multivariable Cox regression [adjusted HR (aHR) = 0.46; 95%CI = 0.22-0.98; P = 0.046]. Finally, the IPTW-RA (adjusted for multiple covariates) was performed, showing a significant risk reduction in the overall population [-14% (95% CI = -23% to -5%)]; at the subgroup restricted analysis, a significant risk reduction (>15%) was observed in the case of GNB-BSI in severely immunocompromised patients (P = 0.003), for SOFA score > 6 (P = 0.014) and in septic shock (P = 0.011). CONCLUSIONS The use of LD + EI/CI of β-lactams in patients with a GNB-BSI may be associated with reduced mortality; also in patients with severe presentation of infection or with additional risk factors, such as immunodepression.
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Affiliation(s)
- Davide Fiore Bavaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Alessandra Belati
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Lucia Diella
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Luisa Frallonardo
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Giacomo Guido
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Roberta Papagni
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Carmen Pellegrino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Gaetano Brindicci
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Nicolò De Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Francesco Di Gennaro
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Sofia Denicolò
- Section of Microbiology and Virology, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Luigi Ronga
- Section of Microbiology and Virology, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Adriana Mosca
- Section of Microbiology and Virology, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Francesco Pomarico
- Hospital Pharmacy Department, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Maria Dell'Aera
- Hospital Pharmacy Department, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Monica Stufano
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Salvatore Grasso
- Anesthesia and Intensive Care Unit, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
| | - Annalisa Saracino
- Clinic of Infectious Diseases, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari, Policlinic of Bari, Piazza Giulio Cesare n. 11, 70124 Bari, Italy
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Monti G, Bradić N, Marzaroli M, Konkayev A, Fominskiy E, Kotani Y, Likhvantsev VV, Momesso E, Nogtev P, Lobreglio R, Redkin I, Toffoletto F, Bruni A, Baiardo Redaelli M, D’Andrea N, Paternoster G, Scandroglio AM, Gallicchio F, Ballestra M, Calabrò MG, Cotoia A, Perone R, Cuffaro R, Montrucchio G, Pota V, Ananiadou S, Lembo R, Musu M, Rauch S, Galbiati C, Pinelli F, Pasin L, Guarracino F, Santarpino G, Agrò FE, Bove T, Corradi F, Forfori F, Longhini F, Cecconi M, Landoni G, Bellomo R, Zangrillo A. Continuous vs Intermittent Meropenem Administration in Critically Ill Patients With Sepsis: The MERCY Randomized Clinical Trial. JAMA 2023; 330:141-151. [PMID: 37326473 PMCID: PMC10276329 DOI: 10.1001/jama.2023.10598] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Abstract
Importance Meropenem is a widely prescribed β-lactam antibiotic. Meropenem exhibits maximum pharmacodynamic efficacy when given by continuous infusion to deliver constant drug levels above the minimal inhibitory concentration. Compared with intermittent administration, continuous administration of meropenem may improve clinical outcomes. Objective To determine whether continuous administration of meropenem reduces a composite of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria compared with intermittent administration in critically ill patients with sepsis. Design, Setting, and Participants A double-blind, randomized clinical trial enrolling critically ill patients with sepsis or septic shock who had been prescribed meropenem by their treating clinicians at 31 intensive care units of 26 hospitals in 4 countries (Croatia, Italy, Kazakhstan, and Russia). Patients were enrolled between June 5, 2018, and August 9, 2022, and the final 90-day follow-up was completed in November 2022. Interventions Patients were randomized to receive an equal dose of the antibiotic meropenem by either continuous administration (n = 303) or intermittent administration (n = 304). Main Outcomes and Measures The primary outcome was a composite of all-cause mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. There were 4 secondary outcomes, including days alive and free from antibiotics at day 28, days alive and free from the intensive care unit at day 28, and all-cause mortality at day 90. Seizures, allergic reactions, and mortality were recorded as adverse events. Results All 607 patients (mean age, 64 [SD, 15] years; 203 were women [33%]) were included in the measurement of the 28-day primary outcome and completed the 90-day mortality follow-up. The majority (369 patients, 61%) had septic shock. The median time from hospital admission to randomization was 9 days (IQR, 3-17 days) and the median duration of meropenem therapy was 11 days (IQR, 6-17 days). Only 1 crossover event was recorded. The primary outcome occurred in 142 patients (47%) in the continuous administration group and in 149 patients (49%) in the intermittent administration group (relative risk, 0.96 [95% CI, 0.81-1.13], P = .60). Of the 4 secondary outcomes, none was statistically significant. No adverse events of seizures or allergic reactions related to the study drug were reported. At 90 days, mortality was 42% both in the continuous administration group (127 of 303 patients) and in the intermittent administration group (127 of 304 patients). Conclusions and Relevance In critically ill patients with sepsis, compared with intermittent administration, the continuous administration of meropenem did not improve the composite outcome of mortality and emergence of pandrug-resistant or extensively drug-resistant bacteria at day 28. Trial Registration ClinicalTrials.gov Identifier: NCT03452839.
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Affiliation(s)
- Giacomo Monti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Nikola Bradić
- Clinical Department of Anesthesiology, Resuscitation and Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
- University North, Varazdin, Croatia
| | - Matteo Marzaroli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Aidos Konkayev
- National Scientific Center of Traumatology and Orthopedia named acad NBatpenov, Astana Medical University, Astana, Kazakhstan
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Kameda Medical Center, Kamogawa, Japan
| | | | - Elena Momesso
- UOC Anestesia Rianimazione Ospedale San Donà di Piave, San Donà di Piave, Italy
| | - Pavel Nogtev
- I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russia
| | - Rosetta Lobreglio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
| | - Ivan Redkin
- Federal Research and Clinical Center of Resuscitation and Rehabilitation, Moscow, Russia
| | - Fabio Toffoletto
- UOC Anestesia Rianimazione Ospedale San Donà di Piave, San Donà di Piave, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Natascia D’Andrea
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
| | | | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Maria Grazia Calabrò
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Romina Perone
- Department of Cardio Thoracic and Vascular Surgery, Pineta Grande Hospital, Pineta Grande, Italy
| | - Raffaele Cuffaro
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giorgia Montrucchio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Vincenzo Pota
- Università della Campania L. Vanvitelli, Napoli, Italy
| | | | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Musu
- Dipartimento di Scienze Mediche e Sanità Pubblica, Università degli Studi di Cagliari, Cagliari, Italy
- Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy
| | - Simon Rauch
- Department of Anaesthesiology and Intensive Care Medicine, Hospital of Merano, Merano, Italy
| | - Carola Galbiati
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fulvio Pinelli
- Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Laura Pasin
- Azienda Ospedale Università Padova, Padua, Italy
| | - Fabio Guarracino
- Dipartimento Anestesia e Rianimazione, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Giuseppe Santarpino
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
- GVM Care and Research, Department of Cardiac Surgery, Città di Lecce Hospital, Lecce, Italy
- Department of Cardiac Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Felice Eugenio Agrò
- Research Unit of Anesthesia and Intensive Care, Department of Medicine and Surgery, Università Campus Bio-Medico, Rome, Italy
- Operative Research Unit of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care Medicine, ASUFC University Hospital of Udine, Udine, Italy
- Department of Medicine, University of Udine, Udine, Italy
| | - Francesco Corradi
- Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Francesco Forfori
- Department of Surgical, Medical, Molecular Pathology, and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Roberts JA, Croom K, Adomakoh N. Continuous infusion of beta-lactam antibiotics: narrative review of systematic reviews, and implications for outpatient parenteral antibiotic therapy. Expert Rev Anti Infect Ther 2023; 21:375-385. [PMID: 36867528 DOI: 10.1080/14787210.2023.2184347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
INTRODUCTION Continuous infusion (CI) of beta-lactam antibiotics may be of benefit in some patients, particularly those with severe infections. However, most studies have been small and conflicting results have been reported. The best available evidence on clinical outcomes of beta-lactam CI comes from systematic reviews/meta-analyses that integrate the available data. AREAS COVERED A search of PubMed from inception to the end of February 2022 for systematic reviews of clinical outcomes with beta-lactam CI for any indication identified 12 reviews, all of which focused on hospitalized patients, most of whom were critically ill. A narrative overview of these systematic reviews/meta-analyses is provided. No systematic reviews evaluating the use of beta-lactam CI for outpatient parenteral antibiotic therapy (OPAT) were identified, as few studies have focused on this area. Relevant data are summarized, and consideration is given to issues that need to be addressed when using beta-lactam CI in the setting of OPAT. EXPERT OPINION Evidence from systematic reviews supports a role for beta-lactam CI in the treatment of hospitalized patients with severe/life-threatening infections. Beta-lactam CI can play a role in patients receiving OPAT for severe chronic/difficult-to-treat infections, but additional data are needed to clarify its optimal use.
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Affiliation(s)
- Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Stewart SD, Allen S, Eisenberg B, Sakakeeny K, Hammond TN, Schneider B, Mochel J, Zhou T. Comparison of the pharmacokinetics of continuous and intermittent infusions of ampicillin-sulbactam in dogs with septic peritonitis. Am J Vet Res 2022; 84:ajvr.22.08.0139. [PMID: 36520648 DOI: 10.2460/ajvr.22.08.0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the time-course of ampicillin-sulbactam and percentage of time that its concentration is above a given MIC (T% > MIC) in dogs with septic peritonitis when delivered as either a continuous infusion (CI) or intermittent infusion (II). ANIMALS 11 dogs with septic peritonitis. PROCEDURES Dogs were randomized to receive ampicillin-sulbactam as either CI or II. Continuous infusions were delivered as a 50 mg/kg bolus IV followed by a rate of 0.1 mg/kg/min. Intermittent infusions were administered as 50 mg/kg IV q8h. Serum ampicillin-sulbactam concentrations were measured at hours 0, 1, 6, and every 12 hours after until patients were transitioned to an oral antimicrobial equivalent. All other care was at the discretion of the attending clinician. Statistical analysis was used to determine each patient's percentage of time T% > MIC for 4 MIC breakpoints (0.25, 1.25, 8, and 16 µg/mL). RESULTS No dogs experienced adverse events related to ampicillin-sulbactam administration. Both CI and II maintained a T% > MIC of 100% of MIC 0.25 µg/mL and MIC 1.25 µg/mL. The CI group maintained a higher T% > MIC for MIC 8 µg/mL and MIC 16 µg/mL; however, these differences did not reach statistical significance (P = .15 and P = .12, respectively). CLINICAL RELEVANCE This study could not demonstrate that ampicillin-sulbactam CI maintains a greater T% > MIC in dogs with septic peritonitis than II; however, marginal differences were noted at higher antimicrobial breakpoints. While these data support the use of antimicrobial CI in septic and critically ill patients, additional prospective trials are needed to fully define the optimal doses and the associated clinical responses.
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Affiliation(s)
- Samuel D Stewart
- Massachusetts Veterinary Referral Hospital, Ethos Veterinary Health, Woburn, MA
| | - Sarah Allen
- Massachusetts Veterinary Referral Hospital, Ethos Veterinary Health, Woburn, MA
| | - Beth Eisenberg
- Massachusetts Veterinary Referral Hospital, Ethos Veterinary Health, Woburn, MA
| | - Katie Sakakeeny
- Department of Emergency and Critical Care, Tufts Veterinary Emergency Treatment and Specialties, Walpole, MA
| | - Tara N Hammond
- Department of Emergency and Critical Care, Tufts Veterinary Emergency Treatment and Specialties, Walpole, MA
| | | | - Jonathan Mochel
- SMART Pharmacology, Iowa State College of Veterinary Medicine, Ames, IA
| | - Tianjian Zhou
- Department of Statistics, Colorado State University, Fort Collins, CO
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8
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Hyun DG, Seo J, Lee SY, Ahn JH, Hong SB, Lim CM, Koh Y, Huh JW. Continuous Piperacillin-Tazobactam Infusion Improves Clinical Outcomes in Critically Ill Patients with Sepsis: A Retrospective, Single-Centre Study. Antibiotics (Basel) 2022; 11:1508. [PMID: 36358163 PMCID: PMC9686508 DOI: 10.3390/antibiotics11111508] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 08/27/2023] Open
Abstract
Continuous infusion of beta-lactam antibiotics has emerged as an alternative for the treatment of sepsis because of the favourable pharmacokinetics of continuous infusion. This study aimed to evaluate the survival benefits of continuous vs. intermittent infusion of piperacillin-tazobactam in critically ill patients with sepsis. We retrospectively conducted a single-centre study of continuous infusion vs. intermittent infusion of piperacillin-tazobactam for adult patients who met the Sepsis-3 criteria and were treated at a medical ICU within 48 h after hospitalisation between 1 May 2018 and 30 April 2020. The primary outcome was mortality at 28 days. A total of 157 patients (47 in the continuous group and 110 in the intermittent group) met the inclusion criteria for evaluation. The 28-day mortality rates were 12.8% in the continuous group and 27.3% in the intermittent group (p = 0.07). However, after adjustment for potential covariables, patients in the continuous group (12.8%) showed significantly lower mortality at 28 days than those in the intermittent group (27.3%; adjusted hazard ratio (HR), 0.31; 95% confidence interval (CI), 0.13-0.79; p = 0.013). In sepsis patients, continuous infusion of piperacillin-tazobactam may confer a benefit regarding the avoidance of mortality at 28 days compared with intermittent infusion.
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Affiliation(s)
- Dong-gon Hyun
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jarim Seo
- Department of Pharmacy, Asan Medical Centre,University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Su Yeon Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jee Hwan Ahn
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, Seoul 05505, Korea
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9
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Drwiega EN, Griffith NC, Danziger LH. Pharmacokinetic evaluation of cefiderocol for the treatment of multidrug resistant Gram-negative infections. Expert Opin Drug Metab Toxicol 2022; 18:245-259. [PMID: 35594628 DOI: 10.1080/17425255.2022.2081148] [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: 09/21/2021] [Accepted: 05/19/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Cefiderocol is a siderophore cephalosporin antibiotic and first of its kind approved by the Food and Drug Administration for the treatment of complicated urinary tract infections (cUTI) and hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) in patients 18 years or older caused by susceptible organisms. Cefiderocol's unique mechanism of iron chelation improves Gram-negative membrane penetration as the bacteria's iron uptake mechanism recognizes the chelated iron antibiotic and iron for entry. This also allows for the evasion of cefiderocol from cell entry-related resistance mechanisms. AREAS COVERED This review covers the mechanism of action, resistance mechanisms, pharmacokinetics in various patient populations, and pharmacodynamics. Relevant literature evaluating efficacy and safety are discussed. EXPERT OPINION Limited treatment options are available for the treatment of carbapenem-resistantorganisms. Clinical trials have demonstrated that cefiderocol is no worse than alternative treatment options for cUTIs and HABP/VABP, but more data are currently available to support the use of beta-lactam beta-lactamase inhibitor agents, where susceptible. Mortality differences demonstrated in patients with pneumonia and bloodstream infections must further be explored and logistical and practical considerations regarding susceptibility testing and use as monotherapy vs. combination therapy must be considered prior to confidently recommending cefiderocol for regular use in systemic infections.
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Affiliation(s)
- Emily N Drwiega
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
| | - Nicole C Griffith
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
| | - Larry H Danziger
- College of Pharmacy, University of Illinois at Chicago, Chicaco, IL, USA
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
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10
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Modelled target attainment after temocillin treatment in severe pneumonia: systemic and epithelial lining fluid pharmacokinetics of continuous versus intermittent infusions. Antimicrob Agents Chemother 2022; 66:e0205221. [PMID: 35099273 DOI: 10.1128/aac.02052-21] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives: To describe the population pharmacokinetics of temocillin administered via continuous versus intermittent infusion in critically ill patients with pneumonia. Secondary objectives included characterization of epithelial lining fluid (ELF)/plasma penetration ratios and determination of the probability of target attainment (PTA) for a range of MICs. Methods: Thirty-two mechanically ventilated patients who were treated for pneumonia with 6g of temocillin daily for in vitro sensitive pathogens were assigned either to the II (2g every 8h over 0.5h) or to the CI (6g over 24h after a loading dose of 2g) group. A population pharmacokinetic model was developed using unbound plasma and total ELF concentrations of temocillin and related Monte Carlo simulations were performed to assess PTAs. Results: The AUC0-24 ELF/plasma penetration ratio was 0.73, at steady-state, for both modes of infusion and whatever the level of creatinine clearance. Monte Carlo simulations showed for the minimal pharmacodynamic (PD) targets of 50% T> 1X MIC (II group) and 100% T > 1X MIC (CI group), PK/PD breakpoints of 4 mg/L in plasma and 2 mg/L in ELF and 4mg/L in plasma and ELF, respectively. The breakpoint was 8 mg/L in ELF for both modes of infusion in patients with CLCR<60mL/min. Conclusion: While CI provides better PKPD indexes, the latter remain below available recommendations for systemic infections, except in case of moderate renal impairment, thereby warranting future clinical studies in order to determine the efficacy of temocillin in severe pneumonia.
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11
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Tschumper E, Dupuis K, McCrory K, Pitts W. Evaluation of Prolonged Versus Continuous Infusions of Piperacillin/Tazobactam During Shortages of Small Volume Parenteral Solutions. J Pharm Technol 2021; 37:271-277. [PMID: 34790963 DOI: 10.1177/87551225211034978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: In 2017, a national drug shortage of small volume solutions significantly affected the preparation of intravenous antibiotics. In response, a continuous infusion administration protocol for piperacillin/tazobactam (PIP/TAZ) was implemented. Objective: To compare the outcomes of continuous to prolonged infusions of PIP/TAZ in the setting of drug shortages. Methods: This study is a single-center, retrospective cohort study in a community hospital of patients 18 years and older who received intravenous PIP/TAZ through 2 different dosing strategies of intravenous antibiotics from December 2016 to January 2018. Data were collected for 2 months on patients receiving prolonged infusions of PIP/TAZ prior to November 2017 and for 2 months on patients receiving continuous infusions of PIP/TAZ after November 2017. Results: A total of 90 patients who received PIP/TAZ via either prolonged (n = 47) or continuous infusion (n = 43) were evaluated. There were no differences between the groups in mortality (3 vs 2 deaths, P = 1.00), length of therapy (6 ± 4 vs 6 ± 3 days, P = .86), or length of stay (9 ± 7 vs 8 ± 6 days, P = .47). Additionally, no differences were noted between incidences of thrombocytopenia (P = .41), Clostridioides difficile infection (P = .48), acute renal failure (P = 1.00), seizures (P = 1.0), or 30-day readmission rates (P = .27). Conclusions: Administration of continuous infusion PIP/TAZ appears to be a viable mitigation strategy during small volume fluid shortages. Future cost-effectiveness studies may provide information on the financial impact of continuous infusions during costly drug shortages.
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Affiliation(s)
- Emily Tschumper
- University of Mississippi, University, MS, USA.,North Mississippi Medical Center, Tupelo, MS, USA
| | | | - Kim McCrory
- North Mississippi Medical Center, Tupelo, MS, USA
| | - Wes Pitts
- North Mississippi Medical Center, Tupelo, MS, USA
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12
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 809] [Impact Index Per Article: 269.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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13
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1305] [Impact Index Per Article: 435.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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14
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Gómez-Junyent J, Rigo-Bonnin R, Benavent E, Soldevila L, Padullés A, Cabo X, Tubau F, Ariza J, Murillo O. Efficacy and Therapeutic Drug Monitoring of Continuous Beta-Lactam Infusion for Osteoarticular Infections Caused by Fluoroquinolone-Resistant Pseudomonas aeruginosa: A Prospective Cohort Study. Eur J Drug Metab Pharmacokinet 2021; 45:587-599. [PMID: 32440843 DOI: 10.1007/s13318-020-00625-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Osteoarticular infections (OIs) caused by fluoroquinolone-resistant Pseudomonas aeruginosa, including multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains, have poor outcomes. We evaluated the outcomes of an optimized strategy of continuous beta-lactam infusion (BL-CI) guided by therapeutic drug monitoring (TDM) for OIs caused by fluoroquinolone-resistant P. aeruginosa. METHODS A prospective observational study of patients with P. aeruginosa OIs in a hospital-based BL-CI program (2016-2018) was carried out. TDM targeting free BL concentrations in plasma (fCss) of at least 3-4 × MIC was performed. We compared failure rates between patients with OIs caused by fluoroquinolone-resistant strains who were treated with BL-CI, with or without colistin, and patients with OIs caused by fluoroquinolone-susceptible strains who were treated with ciprofloxacin. RESULTS Fifty-two patients were included in the study, 19 (36.5%) of whom had OIs caused by fluoroquinolone-resistant P. aeruginosa (13 (68.4%) MDR/XDR strains; 11 (57.9%) device-related infections). The median duration of BL-CI was 36 days; ten patients (52.6%) received BL-colistin combinations. Eighty-two samples were utilized in the TDM, and most patients were found to have a median fCss of 3-10 × MIC; 17 dose adjustments were performed and eight patients needed dose decreases, five of which were due to chronic kidney disease or acute kidney injury (AKI). BL-CI was well tolerated, with the most frequent adverse event being AKI. Failure occurred to 4 patients (21.1%), which was similar to the failure rate of patients with OIs caused by fluoroquinolone-susceptible P. aeruginosa treated with ciprofloxacin (5/30 [16.7%]) (p = 0.699). TDM was also used in the initial BL treatment of patients with OIs caused by susceptible strains before those patients were switched to treatment with ciprofloxacin alone (33 patients, 110 samples, 19 dose adjustments). CONCLUSIONS BL-CI used with/without colistin and supported by TDM may be an alternative and effective treatment option for OIs caused by fluoroquinolone-resistant P. aeruginosa, where limited available therapeutic options exist, especially in the setting of multidrug resistance. Future research should elucidate whether this strategy can produce outcomes similar to those of patients treated for OIs caused by fluoroquinolone-susceptible strains.
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Affiliation(s)
- Joan Gómez-Junyent
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Raul Rigo-Bonnin
- Department of Clinical Laboratory, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eva Benavent
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Laura Soldevila
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ariadna Padullés
- Department of Pharmacy, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Xavier Cabo
- Department of Orthopedics, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Fe Tubau
- Department of Microbiology, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Ariza
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oscar Murillo
- Department of Infectious Diseases, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Feixa Llarga s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
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15
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Rakete S, Schuster C, Paal M, Vogeser M. An isotope-dilution LC-MS/MS method for the simultaneous quantification of meropenem and its open-ring metabolite in serum. J Pharm Biomed Anal 2021; 197:113944. [PMID: 33588299 DOI: 10.1016/j.jpba.2021.113944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/22/2021] [Accepted: 01/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of beta-lactam antibiotics and, among them, especially meropenem gains importance in the field of laboratory medicine. Meropenem is known to be unstable, resulting in a degradation product with an open beta-lactam ring. For a more comprehensive TDM of meropenem, the aim was to develop a LC-MS/MS method for the simultaneous quantification of meropenem and its main degradation product, the open-ring metabolite (ORM). METHODS The method involves a protein precipitation followed by chromatographic separation using a formic acid-ammonium formate methanol gradient on a pentafluorophenyl column. Multiple reaction monitoring in the positive ion mode and stable isotope labeled internal standards were used for quantification. Validation was performed according to the European Medicines Agency guideline. RESULTS Validation was successful performed within the linear drug concentration range of 1.0-100.0 mg/l for meropenem and 0.62-62.30 mg/l for the ORM. Investigation of selectivity, accuracy and precision showed good results and potential matrix effects were successfully compensated by the internal standards. The suitability of the method was shown by the comparison of 35 anonymized leftover serum samples from intensive care patients with routine analyses. CONCLUSION For the first time, we herein describe a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for the simultaneous quantification of meropenem and its ORM in human serum. The ratio of active to inactive compound provides valuable pharmaceutical and pharmacokinetic information, which may contribute to therapeutic efficacy.
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Affiliation(s)
- Sophie Rakete
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany.
| | - Carina Schuster
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
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16
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Thabet P, Joshi A, MacDonald E, Hutton B, Cheng W, Stevens A, Kanji S. Clinical and pharmacokinetic/dynamic outcomes of prolonged infusions of beta-lactam antimicrobials: An overview of systematic reviews. PLoS One 2021; 16:e0244966. [PMID: 33481817 PMCID: PMC7822342 DOI: 10.1371/journal.pone.0244966] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 12/19/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This overview of reviews aims to map and compare of objectives, methods, and findings of existing systematic reviews to develop a greater understanding of the information available about prolonged beta-lactam infusions in hospitalized patients with infection. DESIGN Overview of systematic reviews. DATA SOURCES Medline, Embase, PROSPERO and the Cochrane Library were systematically searched from January, 1990 to June, 2019 using a peer reviewed search strategy. Grey literature was also searched for relevant reviews. ELIGIBILITY CRITERIA FOR SELECTING REVIEWS Systematic reviews were sought that compared two or more infusion strategies for intravenous beta-lactam antimicrobials and report clinical cure or mortality. Populations of included reviews were restricted to hospitalized patients with infection, without restrictions on age, infection type, or disease. DATA EXTRACTION AND ANALYSIS Abstract screening, data extraction, quality and risk of bias assessment were conducted by two independent reviewers. Overlap between reviews was assessed using a modified corrected covered area. Overview findings are reported in accordance with Cochrane's recommendation for overview conduct. Clinical outcomes extracted included survival, clinical cure, treatment failure, microbiological cure, length of stay, adverse events, cost, and emergence of resistance. RESULTS The search strategy identified 3327 unique citations from which 21 eligible reviews were included. Reviews varied by population, intervention and outcomes studied. Between reviews, overlap of primary studies was generally high, methodologic quality generally low and risk of bias variable. Nine of 14 reviews that quantitatively evaluated mortality and clinical cure identified a benefit with prolonged infusions of beta lactams when compared with intermittent infusions. Evidence of mortality and clinical cure benefit was greater among critically ill patients when compared to less sick patients and lower in randomized controlled trials when compared with observational studies. CONCLUSIONS Findings from our review demonstrate a consistent and reproducible lack of harm with prolonged infusions of beta-lactam antibiotics with variability in effect size and significance of benefits. Despite 21 systematic reviews addressing prolonged infusions of beta-lactams, this overview supports the continued need for a definitive systematic review given variability in populations, interventions and outcomes in the current systematic reviews. Subsequent systematic reviews should have more rigorous and transparent methods, only include RCTs and evaluate the proposed benefits found in various subgroup-analyses-i.e. high risk of mortality. TRIAL REGISTRATION Prospero registry, CRD42019117118.
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Affiliation(s)
| | - Anchal Joshi
- University of Waterloo, Waterloo, Ontario, Canada
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Canada
| | - Wei Cheng
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Salmaan Kanji
- The Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Canada
- * E-mail:
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17
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Kondo Y, Ota K, Imura H, Hara N, Shime N. Prolonged versus intermittent β-lactam antibiotics intravenous infusion strategy in sepsis or septic shock patients: a systematic review with meta-analysis and trial sequential analysis of randomized trials. J Intensive Care 2020; 8:77. [PMID: 33042550 PMCID: PMC7541232 DOI: 10.1186/s40560-020-00490-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/09/2020] [Indexed: 01/17/2023] Open
Abstract
Background The prolonged β-lactam infusion strategy has emerged as the standard treatment for sepsis or septic shock despite its unknown efficacy. This study aimed to assess the efficacy of prolonged versus intermittent β-lactam antibiotics infusion on outcomes in sepsis or septic shock patients by conducting a systematic review and meta-analysis. Methods A thorough search was conducted on MEDLINE, the Cochrane Central Register of Controlled Trials, and the Igaku Chuo Zasshi databases. Randomized controlled trials (RCTs) comparing mortality between prolonged and intermittent infusion in adult patients with sepsis or septic shock were included. The primary outcome was hospital mortality. The secondary outcomes were the attainment of the target plasma concentration, clinical cure, adverse events, and occurrence of antibiotic-resistant bacteria. We performed a subgroup analysis stratified according to the year of publication before or after 2015 and a trial sequential analysis (TSA). The Der Simonian–Laird random-effects models were subsequently used to report the pooled risk ratios (RR) with confidence intervals (CI). Results We identified 2869 studies from the 3 databases, and 13 studies were included in the meta-analysis. Hospital mortality did not decrease (RR 0.69 [95%CI 0.47–1.02]) in the prolonged infusion group. The attainment of the target plasma concentration and clinical cure significantly improved (RR 0.40 [95%CI 0.21–0.75] and RR 0.84 [95%CI 0.73–0.97], respectively) in the prolonged infusion group. There were, however, no significant differences in the adverse events and the occurrence of antibiotic-resistant bacteria between the groups (RR 1.01 (95%CI 0.95–1.06) and RR 0.53 [95%CI 0.10–2.83], respectively). For the subgroup analysis, a significant improvement in hospital mortality or clinical cure was reported in studies published in or after 2015 (RR 0.66 [95%CI 0.44–0.98] and RR 0.67 [95%CI 0.50–0.90], respectively). The results of the TSA indicated an insufficient number of studies for a definitive analysis. Conclusions The prolonged infusion of β-lactam antibiotics significantly improved upon attaining the target plasma concentration and clinical cure without increasing the adverse event or the occurrence of antibiotic-resistant bacteria. Prolonged infusion could not improve hospital mortality although an improvement was shown for studies published in or after 2015. Further studies are warranted as suggested by our TSA results.
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Affiliation(s)
- Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1 Tomioka, Urayasu, Chiba, 279-0021 Japan
| | - Kohei Ota
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551 Japan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa Hospital, Otowachinjicho 2, Kyoto-shi, Yamashina-ku, Kyoto, 607-8062 Japan
| | - Naoki Hara
- Japan Organization of Occupational Health and Safety, Yokohama Rosai Hospital, 3211 Kozukue, Kohoku, Yokohama, Kanagawa 222-0036 Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical & Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551 Japan
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18
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Vercheval C, Sadzot B, Maes N, Denooz R, Damas P, Frippiat F. Continuous infusion of cefepime and neurotoxicity: a retrospective cohort study. Clin Microbiol Infect 2020; 27:S1198-743X(20)30386-4. [PMID: 32653661 DOI: 10.1016/j.cmi.2020.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Neurotoxicity related to cefepime is increasingly reported in the literature but specific data concerning continuous infusion (CI) of the drug are still lacking. Our primary objective was to evaluate the incidence of neurotoxicity related to CI of cefepime and the associated risk factors. Our secondary objectives were to analyse the plasma cefepime concentrations and to define the threshold above which neurotoxicity occurs. METHODS In this single-centre retrospective cohort study, all adult patients who underwent at least one cefepime therapeutic drug monitoring (TDM) and were treated with CI of 4 g/day between January 2017 and June 2019 were included. Neurotoxicity was evaluated according to a strict definition and was correlated with steady-state concentration at the time of toxicity presentation. RESULTS Ninety-eight patients with 201 cefepime TDM studies were included, with an incidence of neurotoxicity of 14.3% (14/98). Patients with neurotoxicity had more often underlying brain disease (35.7% (5/14) vs 11.9% (10/84), p = 0.030)) and higher steady-state concentrations (mean ± standard deviation 71.8 ± 32.9 mg/L vs 49.6 ± 30.6, p = 0.036) than the others. A receiver operating characteristic curve analysis yielded a cefepime steady-state concentration of 63.2 mg/L as the best cut-off point between patients with or without neurotoxicity. A mean steady-state concentration of 46.4 mg/L was achieved if the dosages of cefepime were adapted to renal function which was under our threshold concentration but above our highest pharmacokinetic/pharmacodynamic target of 32-40 mg/L. CONCLUSIONS Our results suggest that 4 g/day of cefepime adapted to renal function and infused over 24 h is a trade-off for the risk/benefit ratio, when used empirically.
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Affiliation(s)
- C Vercheval
- Department of Clinical Pharmacy, University Hospital of Liège, Liège, Belgium; Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
| | - B Sadzot
- Department of Neurology, University Hospital of Liège, Liège, Belgium
| | - N Maes
- Department of Biostatistics and Medico-Economic Information, University Hospital of Liège, Liège, Belgium
| | - R Denooz
- Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium; Laboratory of Clinical, Forensic, Industrial and Environmental Toxicology, University Hospital of Liege, Belgium
| | - P Damas
- Department of Intensive Care Unit, University Hospital of Liège, Liège, Belgium
| | - F Frippiat
- Department of Infectious Diseases and General Internal Medicine, University Hospital of Liège, Liège, Belgium
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19
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Derendorf H, Heinrichs T, Reimers T, Lebert C, Brinkmann A. Calculated initial parenteral treatment of bacterial infections: Pharmacokinetics and pharmacodynamics. GMS INFECTIOUS DISEASES 2020; 8:Doc17. [PMID: 32373442 PMCID: PMC7186811 DOI: 10.3205/id000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the third chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter features the pharmacokinetic and pharmacodynamics properties of the most frequently used antiinfective agents.
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Affiliation(s)
- Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Tobias Reimers
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Alexander Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Germany
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20
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Hoen B, Varon E, de Debroucker T, Fantin B, Grimprel E, Wolff M, Duval X. Management of acute community-acquired bacterial meningitis (excluding newborns). Long version with arguments. Med Mal Infect 2019; 49:405-441. [DOI: 10.1016/j.medmal.2019.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/08/2019] [Indexed: 10/26/2022]
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21
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Vercheval C, Streel S, Servais AC, Fillet M, Van Hees T. Stability of 90 mg/mL cefuroxime sodium solution for administration by continuous infusion. J Chemother 2019; 30:371-374. [PMID: 30663549 DOI: 10.1080/1120009x.2018.1535950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Continuous infusions of β-lactam antibiotics increase pharmacokinetic/pharmacodynamic target attainment. However, this way of administration brings about some practical issues such as stability. This study aims to determine the stability of a 90 mg/mL cefuroxime sodium solution. Cefuroxime sodium was reconstituted and mixed with 50-mL 0.9% saline to produce 90 mg/mL solution in polypropylene syringes which were stored at 4 °C, 25 °C and 40 °C. Cefuroxime sodium concentration was determined periodically over 14 days using a stability-indicating high-performance liquid chromatographic method with ultra-violet detection. The loss in concentration was less than 10% after 2 days of storage at 25 °C and less than 5% after 14 days of storage at 4 °C. The concentration fell below 60% after 1 day at 40 °C. Solutions darken in appearance with time and heat. A 90 mg/mL cefuroxime sodium solution stored in polypropylene syringes is stable for 2 days at 25 °C and for at least 14 days at 4 °C.
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Affiliation(s)
- Christelle Vercheval
- a Department of Clinical Pharmacy , University Hospital of Liège , Liège , Belgium
| | - Sophie Streel
- b Department of Hospital Pharmacy , University Hospital of Liège , Liège , Belgium
| | - Anne-Catherine Servais
- c Laboratory for the Analysis of Medicines (LAM) , CIRM (Center for Interdisciplinary Research on Medicines), University of Liège , Liège , Belgium
| | - Marianne Fillet
- c Laboratory for the Analysis of Medicines (LAM) , CIRM (Center for Interdisciplinary Research on Medicines), University of Liège , Liège , Belgium
| | - Thierry Van Hees
- a Department of Clinical Pharmacy , University Hospital of Liège , Liège , Belgium
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22
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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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23
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Cunha CB, Opal SM. Antibiotic Stewardship: Strategies to Minimize Antibiotic Resistance While Maximizing Antibiotic Effectiveness. Med Clin North Am 2018; 102:831-843. [PMID: 30126574 DOI: 10.1016/j.mcna.2018.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Empiric therapy of the septic patient in the hospital is challenging. Antibiotic stewardship is concerned with optimizing antibiotic use and minimizing resistance. Clinicians should avoid overcovering and overtreating colonizing organisms in respiratory secretions and urinary catheters. Empiric therapy should take into account the prevalence of multidrug-resistant organisms in the hospital setting. The most effective resistance prevention strategies is to preferentially select a low resistance potential antibiotic, which should be administered in the highest possible dose without toxicity for the shortest duration to eliminate the infection.
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Affiliation(s)
- Cheston B Cunha
- Division of Infectious Disease, Rhode Island Hospital, The Miriam Hospital, Brown University Alpert School of Medicine, 593 Eddy Street, Physicians Office Building, Suite #328, Providence, RI 02903, USA.
| | - Steven M Opal
- Division of Infectious Disease, Rhode Island Hospital, The Miriam Hospital, Brown University Alpert School of Medicine, 593 Eddy Street, Physicians Office Building, Suite #328, Providence, RI 02903, USA
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24
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Bartoletti M, Giannella M, Tedeschi S, Viale P. Opportunistic infections in end stage liver disease. Infect Dis Rep 2018; 10:7621. [PMID: 29721243 PMCID: PMC5907735 DOI: 10.4081/idr.2018.7621] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 02/02/2018] [Indexed: 02/07/2023] Open
Abstract
Liver cirrhosis is the 10th most common cause of death in Western world and infection is associated with a high morbidity and mortality, and represents the leading cause of acute liver decompensation. Patients with end-stage liver disease exhibit an important impairment of immune system. This condition, called cirrhosis-associated immune dysfunction, summarizes both local and systemic immune system alterations in liver cirrhosis that play a pivotal role in determining both the high incidence of infections and the ominous infections related mortality in this population. Another concerning feature of infections in cirrhotic patients is the growing prevalence of multidrug- resistant or extensively drug-resistant pathogens, which are associated with higher mortality, increased length of in-hospital stay and higher healthcare related costs if compared with infection caused by susceptible strains. Finally, patient with liver cirrhosis have several unique pathophysiological characteristics including hypoalbuminemia and reduction binding to proteins; altered distribution; altered clearance of the antimicrobials that can affect the pharmacokinetic/ pharmacodynamic of antimicrobials.
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Affiliation(s)
- Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Maddalena Giannella
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Sara Tedeschi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola-Malpighi Hospital, University of Bologna, Italy
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25
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Perni S, Martini-Gilching K, Prokopovich P. Controlling release kinetics of gentamicin from silica nano-carriers. Colloids Surf A Physicochem Eng Asp 2018. [DOI: 10.1016/j.colsurfa.2017.04.063] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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26
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Ribera A, Soldevila L, Rigo-Bonnin R, Tubau F, Padullés A, Gómez-Junyent J, Ariza J, Murillo O. Beta-lactams in continuous infusion for Gram-negative bacilli osteoarticular infections: an easy method for clinical use. Infection 2018; 46:239-244. [PMID: 29363049 DOI: 10.1007/s15010-018-1116-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 01/16/2018] [Indexed: 12/16/2022]
Abstract
Continuous infusion (CI) of beta-lactams could optimize their pharmacokinetic/pharmacodynamic indices, especially in difficult-to-treat infections. PURPOSE To validate an easy-to-use method to guide beta-lactams dosage in CI (formula). METHODS A retrospective analysis was conducted of a prospectively collected cohort (n = 24 patients) with osteoarticular infections caused by Gram-negative bacilli (GNB) managed with beta-lactams in CI. Beta-lactams dose was calculated using a described formula (daily dose = 24 h × beta-lactam clearance × target "steady-state" concentration) to achieve concentrations above the MIC. We correlated the predicted concentration (Cpred = daily dose/24 h × beta-lactam clearance) with the patient's observed concentration (Cobs) measured by UPLC-MS/MS (Spearman's coefficient). RESULTS The most frequent microorganism treated was P. aeruginosa (21 cases; 9 MDR). Beta-lactams in CI were ceftazidime (n = 14), aztreonam (7), and piperacillin/tazobactam (3), mainly used in combination (12 with colistin, 5 with ciprofloxacin) and administered without notable side effects. The plasma Cobs was higher overall than Cpred; the Spearman correlation between both concentrations was rho = 0.6 (IC 95%: 0.2-0.8) for all beta-lactams, and rho = 0.8 (IC 95%: 0.4-1) for those treated with ceftazidime. CONCLUSIONS The formula may be useful in clinical practice for planning the initial dosage of beta-lactams in CI, while we await a systematic therapeutic drug monitoring. The use of beta-lactams in CI was safe.
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Affiliation(s)
- Alba Ribera
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Laura Soldevila
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Raul Rigo-Bonnin
- Clinical Laboratory Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Fe Tubau
- Microbiology Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain.,Ciber de Enfermedades Respiratorias ISCIII, Madrid, Spain
| | - Ariadna Padullés
- Pharmacy Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Joan Gómez-Junyent
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Javier Ariza
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Oscar Murillo
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Feixa Llarga s/n, Hospitalet de Llobregat, 08907, Barcelona, Spain.
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27
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Wang X, Wu F, Chen Y, Qin F, Bao J, Chen G. Novel pogostone analogous XW-12-loading nanoparticles display enhanced systematic activity against methicillin-resistant Staphylococcus aureus. J Microencapsul 2018; 35:78-89. [PMID: 29308688 DOI: 10.1080/02652048.2018.1425751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Pogostone analogous XW-12 displays an inhibitory effect on Staphylococcus aureus. However, the insolubility of the compound has restricted its further applications. This work aims to improve the water-solubility of XW-12, we used previously synthesised pogostone derivatives XW-12, forming nanoparticles with PLGA-PEG by a single-emulsion solvent-evaporation technique. Characterisations of XW-12 nanoparticles were performed. The in vitro and in vivo experiments confirmed its antimicrobial efficacy and toxicity. The results revealed that the XW-12 NPs had a particle size of approximately 200.0 nm, a slower and sustained release. An antibacterial experiment showed that XW-12 NPs had a lower minimal inhibitory concentration value of 1 μg/mL. In the mouse systemic infection model of MRSA, XW-12 NPs indicated high antibacterial activity. In addition, in vivo, toxicity studies declared that XW-12 NPs had a low cytotoxicity. Therefore, this study suggested that XW-12 NPs may be a great potential antibacterial agent in the treatment of clinical MRSA infection.
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Affiliation(s)
- Xiaoyun Wang
- a School of Life Sciences and Key Laboratory of Bio-resources and Eco-environment , Ministry of Education, Sichuan University , Chengdu , PR China
| | - Fengbo Wu
- b Department of Anaesthesiology and Department of Pharmacy , West China Hospital, Sichuan University , Chengdu , PR China
| | - Yuyu Chen
- a School of Life Sciences and Key Laboratory of Bio-resources and Eco-environment , Ministry of Education, Sichuan University , Chengdu , PR China
| | - Feifei Qin
- b Department of Anaesthesiology and Department of Pharmacy , West China Hospital, Sichuan University , Chengdu , PR China
| | - Jinku Bao
- a School of Life Sciences and Key Laboratory of Bio-resources and Eco-environment , Ministry of Education, Sichuan University , Chengdu , PR China
| | - Guo Chen
- b Department of Anaesthesiology and Department of Pharmacy , West China Hospital, Sichuan University , Chengdu , PR China
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28
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Chan JD, Dellit TH, Lynch JB. Hospital Length of Stay Among Patients Receiving Intermittent Versus Prolonged Piperacillin/Tazobactam Infusion in the Intensive Care Units. J Intensive Care Med 2017; 33:134-141. [PMID: 28486867 DOI: 10.1177/0885066617708756] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We sought to evaluate clinical outcomes of intensive care unit (ICU) patients following a hospital-wide initiative of prolonged piperacillin/tazobactam (PIP/TAZ) infusion. METHODS Retrospective observational study of patients >18 years old who was hospitalized in the ICU receiving PIP/TAZ for >72 hours during the preimplementation (June 1, 2010 to May 31, 2011) and postimplementation (July 7, 2011 to June 30, 2014) periods. RESULTS There were 124 and 429 patients who met inclusion criteria with average age of 54.3 and 56.9 years, and average duration of PIP/TAZ therapy was 6.1 ± 2.8 days and 5.9 ± 3.4 days in the pre- and postimplementation period, respectively. Intensive care unit and hospital length of stay (LOS) following initiation of PIP/TAZ were 8.0 ± 8.4 days versus 6.4 ± 6.8 days and 26.3 ± 22.8 days versus 20.4 ± 16.1 days among patients in the pre- and postimplementation periods, respectively. Compared to patients who received intermittent PIP/TAZ infusion, the adjusted difference in ICU and hospital LOS was 0.6 ± 0.8 days (95% confidence interval [CI]: -0.9 to 2.1 days) and 5.6 ± 2.1 days (95% CI: 1.4 - 9.7 days) shorter among patients who received prolonged PIP/TAZ infusion. At hospital discharge, 19 (15.3%) intermittent infusion and 74 (17.2%) prolonged infusion recipients had died. In comparison to intermittent infusion recipients, the adjusted odds ratio for mortality was 1.17 (95% CI: 0.65-2.1) with prolonged infusion. CONCLUSION Our study demonstrated a reduction in hospital LOS with prolonged PIP/TAZ infusion among critically ill patients. Randomized trials are needed to further validate these findings.
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Affiliation(s)
- Jeannie D Chan
- 1 Department of Pharmacy, Harborview Medical Center, School of Pharmacy, University of Washington, Seattle, WA, USA.,2 Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - Timothy H Dellit
- 2 Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
| | - John B Lynch
- 2 Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center and School of Medicine, University of Washington, Seattle, WA, USA
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29
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Continuous and Prolonged Intravenous β-Lactam Dosing: Implications for the Clinical Laboratory. Clin Microbiol Rev 2017; 29:759-72. [PMID: 27413094 DOI: 10.1128/cmr.00022-16] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Beta-lactam antibiotics serve as a cornerstone in the management of bacterial infections because of their wide spectrum of activity and low toxicity. Since resistance rates among bacteria are continuously on the rise and the pipeline for new antibiotics does not meet this trend, an optimization of current beta-lactam treatment is needed. This review provides an overview of optimization through use of prolonged- and continuous-infusion dosing strategies compared with more traditional intermittent infusions. Included is an overview of the scientific basis for using these nontraditional prolonged- and continuous-infusion-based regimens, with a focus on major areas in which the clinical laboratory can support the clinical use of these regimens.
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31
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Cotrina-Luque J, Gil-Navarro MV, Acosta-García H, Alfaro-Lara ER, Luque-Márquez R, Beltrán-García M, Bautista-Paloma FJ. Continuous versus intermittent piperacillin/tazobactam infusion in infection due to or suspected pseudomonas aeruginosa. Int J Clin Pharm 2016; 38:70-9. [PMID: 26474861 DOI: 10.1007/s11096-015-0208-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 10/06/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is lack of information on the efficacy and safety of piperacillin–tazobactam administered by continuous infusion. OBJECTIVE The aim of this study was to investigate whether continuous infusion of piperacillin–tazobactam is superior in terms of efficacy to a 30 % higher dose administered by intermittent infusion to treat suspected or confirmed infection due to Pseudomonas aeruginosa. Setting Multicenter clinical trial with 11 third level Spanish hospitals. METHOD Randomized, double-blind parallel-group clinical trial, controlled by conventional administration of the drug. Patients randomly assigned in a 1:1 ratio to receive piperacillin–tazobactam as continuous infusion (CI) or intermittent (II). MAIN OUTCOME MEASURE Primary efficacy endpoint was percentage of patients having a satisfactory clinical response at completion of treatment, defined as clinical cure or clinical improvement. Adverse events were reported. Results 78 patients were included, 40 in the CI group and 38 in the II group. Mean (standard deviation) duration of treatment was 7 (±4.44) days. 58 patients (74.4 %) experienced cure or improvement at the end of the treatment. There were no statistical differences in cure rates between the two treatment arms and no adverse events were reported. CONCLUSION Continuous infusion of piperacillin–tazobactam is an alternative administration drug method at least similar in efficacy and safety to conventional intermittent infusion. Multivariate analysis is needed to determine whether continuous administration might be more beneficial than intermittent in certain patient subgroups.
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Xie X, Yang Y, Yang Y, Li Z, Zhang H, Chi Q, Cai X, Mei X. The development and evaluation of a subcutaneous infusion delivery system based on osmotic pump control and gas drive. Drug Deliv 2016; 23:2193-2204. [PMID: 25188841 DOI: 10.3109/10717544.2014.955617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A novel, self-administration drug delivery system for subcutaneous infusion was developed and evaluated. The device includes two main components: an osmotic tablet controlled gas actuator and a syringe catheter system. The sodium carbonate in the osmotic pump tablet will release into the surround citric acid solution and produce CO2 gas, which will drive the drug solution into subcutaneous tissue. The key formulation factors of the osmotic tablet that would influence the infusion profiles of the device were investigated by single factor exploration. The formulation was optimized via a response surface methodology. With an 18 ± 4 min of lag time, the delivery system was able to infuse at an approximate zero-order up to 5.90 ± 0.37 h with a precision of 9.0% RSD (n = 6). A linear correlation was found for the infusion profile and the fitting equation was Y = 0.014X - 0.004 (r = 0.998). A temperature change of 4 °C was found to modify the flow rate by about 12.0%. In vivo results demonstrated that the present subcutaneous infusion device was similar to the commercial infusion pump, and it could bring a long and constant ampicillin plasma level with minimized fluctuations.
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Affiliation(s)
- Xiangyang Xie
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China.,b Department of Pharmacy , Wuhan General Hospital of Guangzhou Military Command , Wuhan , PR China , and
| | - Yang Yang
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Yanfang Yang
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Zhiping Li
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Hui Zhang
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Qiang Chi
- c Department of Pharmacy , The 215th Clinic of 406th Hospital of the Chinese People's Liberation Army , Dalian , China
| | - Xingshi Cai
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
| | - Xingguo Mei
- a Department of Pharmaceutics , Beijing Institute of Pharmacology and Toxicology , Beijing , PR China
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Bates A, Joffe AR. Is there a role for continuous infusion of β-lactam antibiotics in severe sepsis? J Thorac Dis 2016; 8:E437-9. [PMID: 27294248 DOI: 10.21037/jtd.2016.03.81] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Angela Bates
- University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Ari R Joffe
- University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
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Furtado GH, Cardinal L, Macedo RS, Silva JO, Medeiros EA, Kuti JL, Nicolau DP. Pharmacokinetic/pharmacodynamic target attainment of intravenous β-lactam regimens against Gram-negative bacteria isolated in a Brazilian teaching hospital. Rev Soc Bras Med Trop 2015; 48:539-45. [DOI: 10.1590/0037-8682-0122-2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 07/28/2015] [Indexed: 11/22/2022] Open
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Ribera A, Benavent E, Lora-Tamayo J, Tubau F, Pedrero S, Cabo X, Ariza J, Murillo O. Osteoarticular infection caused by MDR Pseudomonas aeruginosa: the benefits of combination therapy with colistin plus β-lactams. J Antimicrob Chemother 2015; 70:3357-65. [PMID: 26419763 DOI: 10.1093/jac/dkv281] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/11/2015] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES In the era of emergence of MDR Pseudomonas aeruginosa, osteoarticular infections (OIs) add more difficulties to its treatment. The role of β-lactams (BLs) is questioned and older drugs need to be reconsidered. The objective of this study was to describe our experience in the management of OIs caused by MDR P. aeruginosa and evaluate different therapeutic options. METHODS This was a retrospective analysis of a prospectively collected cohort (2004-13) of patients with OI caused by MDR P. aeruginosa. We created two groups: (i) Group A (more difficult to treat), prosthetic joint infections (PJIs) and osteoarthritis (OA) managed with device retention; and (ii) Group B (less difficult to treat), OA managed without device retention. Antibiotic treatment was administered according to clinician criteria: monotherapy/combined therapy; and BL used by intermittent bolus (IB)/continuous infusion. RESULTS Of 34 patients, 15 (44.1%) had PJI and 19 (55.9%) had OA (8 related to an orthopaedic device). Twenty-three cases (68%) were caused by XDR P. aeruginosa. The initial management included removal of an orthopaedic device in 14 cases, together with antibiotic [alone, 19 (55.9%; 4 colistin, 14 BL-IB and 1 BL continuous infusion); and in combination, 15 (44.1%; 5 BL-IB and 10 BL continuous infusion)]. The overall cure rate was 50% (39% and 63% in Groups A and B, respectively), ranging from 31.6% with monotherapy to 73.3% with combined therapy (P = 0.016), with special interest within Group A (cure rate with combined therapy 71.4%, P = 0.049). After rescue therapy, which included removal of remaining devices, the cure rate reached 85.3%. CONCLUSIONS We suggest that the BL/colistin combination is an optimized therapy for OI caused by MDR P. aeruginosa, together with an appropriate surgical treatment.
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Affiliation(s)
- Alba Ribera
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Eva Benavent
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Jaime Lora-Tamayo
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Fe Tubau
- Microbiology Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain Ciber de Enfermedades Respiratorias ISCIII, Madrid, Spain
| | - Salvador Pedrero
- Orthopaedic Surgery Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Xavier Cabo
- Orthopaedic Surgery Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Javier Ariza
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Oscar Murillo
- Infectious Diseases Department, IDIBELL-Hospital Universitari de Bellvitge, Barcelona, Spain
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Roberts JA, Lipman J. Tissue Distribution of Beta-Lactam Antibiotics: Continuous versus Bolus Dosing. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2009.tb00457.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jason A Roberts
- School of Medicine; The University of Queensland, and Clinical Pharmacist, Royal Brisbane and Women's Hospital
| | - Jeffrey Lipman
- Department of Intensive Care; Royal Brisbane and Women's Hospital; Brisbane Queensland
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Jamal JA, Roberts DM, Udy AA, Mat-Nor MB, Mohamad-Nor FS, Wallis SC, Lipman J, Roberts JA. Pharmacokinetics of piperacillin in critically ill patients receiving continuous venovenous haemofiltration: A randomised controlled trial of continuous infusion versus intermittent bolus administration. Int J Antimicrob Agents 2015; 46:39-44. [PMID: 25881872 DOI: 10.1016/j.ijantimicag.2015.02.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/26/2022]
Abstract
Here we describe the pharmacokinetics of piperacillin administered by continuous infusion (CI) versus intermittent bolus (IB) dosing in critically ill patients receiving continuous venovenous haemofiltration (CVVH) and compare the frequency of pharmacodynamic/pharmacokinetic (PK/PD) target attainment with each dosing strategy. This was a prospective pharmacokinetic trial in 16 critically ill patients with severe sepsis or septic shock undergoing CVVH and randomised to receive either CI or IB administration of a standard daily dose of piperacillin/tazobactam (11.25g/day on Day 1 followed by 9g/day). Serial blood samples were measured on two occasions. Piperacillin pharmacokinetics were calculated using a non-compartmental approach. Blood concentrations were compared with established PK/PD targets. On occasion 1 (Days 1-3 of therapy), IB administration resulted in significantly higher piperacillin peak concentrations (169 vs. 89mg/L; P=0.002), whereas significantly higher steady-state concentrations were observed in CI patients (83 vs. 57mg/L; P=0.04). Total clearance and clearance not mediated by CVVH were significantly higher with CI administration [median (interquartile range), 1.0 (0.7-1.1) and 0.8 (0.6-1.0)mL/kg/min; P=0.001 and 0.001, respectively]. The estimated unbound piperacillin concentrations were four times above the target susceptibility breakpoint (16mg/L) for the entire dosing interval (100%fT>4xMIC) in 87.5% of patients receiving CI administration (sampling occasion 1), compared with 62.5% of IB patients achieving the desired target (50%fT>4xMIC). Compared with IB dosing, and despite similar CVVH settings, CI administration of piperacillin results in a pharmacokinetic profile that may optimise outcomes for less susceptible pathogens.
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Affiliation(s)
- Janattul-Ain Jamal
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Darren M Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Andrew A Udy
- Department of Hyperbaric and Intensive Care Medicine, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria, Australia
| | - Mohd-Basri Mat-Nor
- Department of Anaesthesiology and Intensive Care, Kulliyyah of Medicine, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
| | | | - Steven C Wallis
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Intensive Care Medicine, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Department of Pharmacy, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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Burgess SV, Mabasa VH, Chow I, Ensom MHH. Evaluating outcomes of alternative dosing strategies for cefepime: a qualitative systematic review. Ann Pharmacother 2015; 49:311-22. [PMID: 25575975 DOI: 10.1177/1060028014564179] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To perform a qualitative systematic review of the evidence comparing traditional with prolonged intermittent or continuous infusions of cefepime based on clinical and pharmacodynamic outcomes. DATA SOURCES PubMed (1946 to October 2014), EMBASE (1980 to October 2014), CENTRAL, Cochrane Database of Systematic Reviews, Web of Science, and International Pharmaceutical Abstracts (1970 to October 2014) were searched using the terms cefepime, pharmacokinetics, pharmacodynamics, drug administration, intravenous infusions, intravenous drug administration, continuous infusion, extended infusion, and intermittent therapy. Reference lists from relevant materials were reviewed. STUDY SELECTION AND DATA EXTRACTION Articles evaluating administration regimens of cefepime, one of which included the traditional, manufacturer-recommended 0.5-hour infusion and the other a prolonged or continuous infusion were included. Prespecified clinical outcomes of interest included all-cause mortality, length of hospital stay, clinical cure, and adverse events. The primary pharmacodynamic outcome was percentage time of unbound drug concentration remaining above the minimum inhibitory concentration. DATA SYNTHESIS In all, 18 studies were included; 6 studies assessed clinical outcomes, and 12 assessed pharmacodynamic outcomes. Prolonged or continuous infusions of cefepime achieved the pharmacodynamic targets more often than traditional infusions. The association of improved clinical outcomes with prolonged or continuous infusions is unclear. All-cause mortality was significantly decreased with the use of a prolonged cefepime infusion in a retrospective study. Two prospective, randomized studies demonstrated no statistically significant difference in mortality between prolonged and intermittent infusions. CONCLUSIONS The available literature on prolonged and continuous infusions of cefepime demonstrated an improved achievement of pharmacodynamic targets; however, the effect on clinical outcomes is inconclusive. Well-designed prospective studies are required to determine optimal dosing and administration strategies.
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Affiliation(s)
| | | | | | - Mary H H Ensom
- Children's and Women's Health Centre of British Columbia, Vancouver, BC, Canada
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Yang H, Zhang C, Zhou Q, Wang Y, Chen L. Clinical outcomes with alternative dosing strategies for piperacillin/tazobactam: a systematic review and meta-analysis. PLoS One 2015; 10:e0116769. [PMID: 25575030 PMCID: PMC4289069 DOI: 10.1371/journal.pone.0116769] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 12/12/2014] [Indexed: 12/03/2022] Open
Abstract
Objectives A better dosing strategy can improve clinical outcomes for patients. We sought to compare the extended or continuous infusion with conventional intermittent infusion of piperacillin/tazobactam, investigating which approach is better and worthy of recommendation for clinical use. Methods Articles were gathered from PubMed, Web of Science, ProQuest, Science Direct, Cochrane, two Chinese literature databases (CNKI, Wan Fang Data) and related ICAAC and ACCP conferences. Randomized controlled and observational studies that compared extended or continuous infusion with conventional intermittent infusion of piperacillin/tazobactam were identified from the databases above and analyzed. Two reviewers independently extracted and investigated the data. A meta-analysis was performed using Revman 5.2 software. The quality of each study was assessed. Sensitivity analysis and publication bias were evaluated. Results Five randomized controlled trials and nine observational studies were included in this study. All included studies had high quality and no publication bias was found. Compared to the conventional intermittent infusion approach, the extended or continuous infusion group had a significantly higher clinical cure rate (OR 1.88, 95% CI 1.29-2.73, P = 0.0009) and a lower mortality rate (OR 0.67, 95% CI 0.50-0.89, P = 0.005). No statistical difference was observed for bacteriologic cure (OR 1.40, 95% CI 0.82-2.37, P = 0.22) between the two dosing regimens. The sensitivity analysis showed the results were stable. Conclusions Our systematic review and meta-analysis suggested that the extended or continuous infusion strategy of piperacillin/tazobactam should be recommended for clinical use considering its higher clinical cure rate and lower mortality rate in comparison with conventional intermittent strategy. Data from this study could be extrapolated for other β-lactam antimicrobials. Therefore, this dosing strategy could be considered in clinical practice.
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Affiliation(s)
- Hui Yang
- Department of pharmacy, Peking University Third Hospital, Beijing, China
- School of pharmaceutical sciences, Peking University, Beijing, China
| | - Chao Zhang
- Department of pharmacy, Peking University Third Hospital, Beijing, China
- * E-mail:
| | - Quanyu Zhou
- Department of pharmacy, The First People’s Hospital of Lianyungang, Jiangsu, China
| | - Yike Wang
- School of pharmaceutical sciences, Peking University, Beijing, China
| | - Lujia Chen
- School of pharmaceutical sciences, Peking University, Beijing, China
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Antibiothérapie au cours de l’épuration extrarénale continue en réanimation. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0935-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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De Waele JJ, Lipman J, Akova M, Bassetti M, Dimopoulos G, Kaukonen M, Koulenti D, Martin C, Montravers P, Rello J, Rhodes A, Udy AA, Starr T, Wallis SC, Roberts JA. Risk factors for target non-attainment during empirical treatment with β-lactam antibiotics in critically ill patients. Intensive Care Med 2014; 40:1340-51. [PMID: 25053248 DOI: 10.1007/s00134-014-3403-8] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 07/10/2014] [Indexed: 12/27/2022]
Abstract
PURPOSE Risk factors for β-lactam antibiotic underdosing in critically ill patients have not been described in large-scale studies. The objective of this study was to describe pharmacokinetic/pharmacodynamic (PK/PD) target non-attainment envisioning empirical dosing in critically ill patients and considering a worst-case scenario as well as to identify patient characteristics that are associated with target non-attainment. METHODS This analysis uses data from the DALI study, a prospective, multi-centre pharmacokinetic point-prevalence study. For this analysis, we assumed that these were the concentrations that would be reached during empirical dosing, and calculated target attainment using a hypothetical target minimum inhibitory concentration (MIC), namely the susceptibility breakpoint of the least susceptible organism for which that antibiotic is commonly used. PK/PD targets were free drug concentration maintained above the MIC of the suspected pathogen for at least 50 % and 100 % of the dosing interval respectively (50 % and 100 % f T (>MIC)). Multivariable analysis was performed to identify factors associated with inadequate antibiotic exposure. RESULTS A total of 343 critically ill patients receiving eight different β-lactam antibiotics were included. The median (interquartile range) age was 60 (47-73) years, APACHE II score was 18 (13-24). In the hypothetical situation of empirical dosing, antibiotic concentrations remained below the MIC during 50 % and 100 % of the dosing interval in 66 (19.2 %) and 142 (41.4 %) patients respectively. The use of intermittent infusion was significantly associated with increased risk of non-attainment for both targets; creatinine clearance was independently associated with not reaching the 100 % f T( >MIC) target. CONCLUSIONS This study found that-in empirical dosing and considering a worst--case scenario--19 % and 41 % of the patients would not achieve antibiotic concentrations above the MIC during 50 % and 100 % of the dosing interval. The use of intermittent infusion (compared to extended and continuous infusion) was the main determinant of non-attainment for both targets; increasing creatinine clearance was also associated with not attaining concentrations above the MIC for the whole dosing interval. In the light of this study from 68 ICUs across ten countries, we believe current empiric dosing recommendations for ICU patients are inadequate to effectively cover a broad range of susceptible organisms and need to be reconsidered.
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Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium,
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Attivi D, Gibaud S. Continuous infusion of piperacillin/tazobactam in patients with severe infections: A possible pharmacokinetic optimisation? ANNALES PHARMACEUTIQUES FRANÇAISES 2014; 72:146-51. [DOI: 10.1016/j.pharma.2013.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 12/12/2013] [Accepted: 12/19/2013] [Indexed: 11/30/2022]
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Goulenok T, Fantin B. Antimicrobial treatment of febrile neutropenia: pharmacokinetic-pharmacodynamic considerations. Clin Pharmacokinet 2014; 52:869-83. [PMID: 23807657 DOI: 10.1007/s40262-013-0086-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with cancer or hematologic diseases are particularly at risk of infection leading to high morbidity, mortality and costs. Extensive data show that optimization of the administration of antimicrobials according to their pharmacokinetic and pharmacodynamic parameters improves clinical outcome. Evidence is growing that when pharmacokinetic and pharmacodynamic parameters are used to target not only clinical cure but also eradication, the selection resistance is also contained. This is of particular importance in patients with neutropenia in whom increasing rates of drug-resistant Gram-negative bacteria have been reported, particularly Pseudomonas aeruginosa. Based on experimental and clinical studies, pharmacokinetic and pharmacodynamic parameters are discussed in this review for each antibiotic used in febrile neutropenia in order to help physicians improve dosing and optimization of antimicrobial agents.
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Affiliation(s)
- Tiphaine Goulenok
- Internal Medicine Department, Beaujon Hospital, APHP and University Paris Diderot, Sorbonne Paris Cité, Paris, France
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Anlicoara R, Ferraz ÁAB, da P. Coelho K, de Lima Filho JL, Siqueira LT, de Araújo JGC, Campos JM, Ferraz EM. Antibiotic Prophylaxis in Bariatric Surgery with Continuous Infusion of Cefazolin: Determination of Concentration in Adipose Tissue. Obes Surg 2014; 24:1487-91. [DOI: 10.1007/s11695-014-1231-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Pharmacokinetics of ertapenem in critically ill patients receiving continuous venovenous hemodialysis or hemodiafiltration. Antimicrob Agents Chemother 2013; 58:1320-6. [PMID: 24323468 DOI: 10.1128/aac.02090-12] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study characterizes the pharmacokinetics of ertapenem, a carbapenem antibiotic, in critically ill adult subjects receiving continuous renal replacement therapy (CRRT). Eight critically ill patients with suspected/known Gram-negative infections receiving continuous venovenous hemodialysis (CVVHD) or continuous venovenous hemodiafiltration (CVVHDF) and ertapenem were enrolled. One gram of ertapenem was infused over 30 min. Predialyzer blood samples were drawn with the first dose of ertapenem from the hemodialysis tubing at time zero, 30 min, and 1, 2, 4, 8, 12, 18, and 24 h after the start of the ertapenem infusion. Effluent was collected at the same time points. Ertapenem total serum, unbound serum, and effluent concentrations from all eight subjects were used simultaneously to perform a population compartmental pharmacokinetic modeling procedure using NONMEM. Monte Carlo simulations were performed to evaluate the ability of several ertapenem dosing regimens (500 mg once daily, 750 mg once daily, 500 mg twice daily, and 1,000 mg once daily) to obtain effective unbound serum concentrations above 0.5, 1, and 2 μg/ml. For our simulated patients, all regimens produced unbound ertapenem concentrations above 2 μg/ml for 40% of the dosing interval for at least 96% of simulated patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT00877370.).
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Huang H, Huang S, Zhu P, Xi X. Continuous versus intermittent infusion of cefepime in neurosurgical patients with post-operative intracranial infections. Int J Antimicrob Agents 2013; 43:68-72. [PMID: 24139880 DOI: 10.1016/j.ijantimicag.2013.08.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 08/08/2013] [Accepted: 08/16/2013] [Indexed: 10/26/2022]
Abstract
Cefepime is administered as an intermittent infusion (II); however, continuous infusion (CI) may be advantageous because β-lactam antibiotics exhibit time-dependent antibacterial activity. This retrospective, non-randomised, comparative study included 68 neurosurgical patients with post-operative intracranial infections treated with 4g/day cefepime over 24h as a CI (n=34) or 2g every 12h as II (n=34). CI controlled the intracranial infection more rapidly and effectively than II (6.6±1.9 days vs. 7.8±2.6 days; P=0.036). By considering the minimum inhibitory concentrations (MICs) to be 4μg/mL and 8μg/mL, the percentage of time when the cefepime plasma or CSF concentrations were higher than the MIC (%T>MIC) was calculated for each patient. For plasma cefepime concentrations, the %T(>MIC) in the CI group was higher than in the II group (for MICs of 8μg/mL, 100% vs. 75%, respectively). The mean calculated area under the curve (AUC) in the CI group was similar to the II group (1197.99±72.15μgh/mL vs. 890.84±140.78μgh/mL; P=0.655). For CSF cefepime concentrations, the %T(>MIC) in the CI group was higher than in the II group (for MICs of 4μg/mL and 8μg/mL, 83.3% and 75% vs. 25% and 0%, respectively). The mean calculated AUC for the CI group was higher than the II group (220.56±13.59μgh/mL vs. 86.34±5.69μgh/mL; P=0.003). Therefore, CI of cefepime significantly enhanced the antibacterial effect and reduced the treatment duration in neurosurgical patients with post-operative intracranial infections.
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Affiliation(s)
- Huawei Huang
- Department of Critical Care Medicine, Beijing Fuxing Hospital, Capital Medical University, Beijing 100038, PR China
| | - Shengyue Huang
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, Fuzhou 350001, PR China
| | - Pengli Zhu
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fuzhou 350001, PR China.
| | - Xiuming Xi
- Department of Critical Care Medicine, Beijing Fuxing Hospital, Capital Medical University, Beijing 100038, PR China.
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Udy AA, Roberts JA, Lipman J. Clinical implications of antibiotic pharmacokinetic principles in the critically ill. Intensive Care Med 2013; 39:2070-82. [DOI: 10.1007/s00134-013-3088-4] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/23/2013] [Indexed: 12/21/2022]
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Shan Q, Yang F, Wang J, Ding H, He L, Zeng Z. Pharmacokinetic/pharmacodynamic relationship of cefquinome against Pasteurella multocida in a tissue-cage model in yellow cattle. J Vet Pharmacol Ther 2013; 37:178-85. [PMID: 23980645 DOI: 10.1111/jvp.12076] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 07/15/2013] [Indexed: 11/29/2022]
Abstract
The cephalosporin antimicrobial drug cefquinome was administered to yellow cattle intravenously (i.v.) and intramuscularly (i.m.) at a dose of 1 mg/kg of body weight in a two-period crossover study. The pharmacokinetic (PK) properties of cefquinome in serum, inflamed tissue-cage fluid (exudate), and noninflamed tissue-cage fluid (transudate) were studied using a tissue-cage model. The in vitro and ex vivo activities of cefquinome in serum, exudate, and transudate against a pathogenic strain of Pasteurella multocida (P. multocida) were determined. A concentration-independent antimicrobial activity of cefquinome was confirmed for levels lower than 4 × MIC. Integration of in vivo pharmacokinetic data with the in vitro MIC provided mean values for the time that drug levels remain above the MIC (T > MIC) in serum was 14.10 h after intravenous and 14.46 h after intramuscular dosing, indicating a likely high level of effectiveness in clinical infections caused by P. multocida of MIC 0.04 μg/mL or less. These data may be used as a rational basis for setting dosing schedules, which optimize clinical efficacy and minimize the opportunities for emergence of resistant organisms.
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Affiliation(s)
- Q Shan
- National Reference Laboratory of Veterinary Drug Residues (SCAU), College of Veterinary Medicine, South China Agricultural University, Guangzhou, China; Pearl River Fisheries Research Institute, Chinese Academy of Fishery Sciences, Guangzhou, China
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49
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Asín-Prieto E, Rodríguez-Gascón A, Trocóniz IF, Soraluce A, Maynar J, Sánchez-Izquierdo JÁ, Isla A. Population pharmacokinetics of piperacillin and tazobactam in critically ill patients undergoing continuous renal replacement therapy: application to pharmacokinetic/pharmacodynamic analysis. J Antimicrob Chemother 2013; 69:180-9. [PMID: 23908259 DOI: 10.1093/jac/dkt304] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES To evaluate the pharmacokinetics of piperacillin/tazobactam in critically ill patients undergoing continuous renal replacement therapy (CRRT) and to assess the success of the therapy against susceptible bacteria. PATIENTS AND METHODS Sixteen patients undergoing CRRT with different degrees of renal function were included in the study. Blood and ultrafiltrate samples were drawn after administration of piperacillin/tazobactam (4/0.5 g) every 4, 6 or 8 h. The data were analysed by a population approach using NONMEM 7.2. The probability of target attainment (PTA) of maintaining free piperacillin levels above the MIC during the entire dosing interval was estimated by simulation of intermittent and continuous infusions. RESULTS The pharmacokinetics of piperacillin and tazobactam were best described by two-compartment models where the elimination of both drugs was conditioned by renal [dependent on creatinine clearance (CLCR)], non-renal and extracorporeal clearances. A 20 min infusion of piperacillin/tazobactam administered every 6 h provided high PTAs against MICs ≤ 32 mg/L in patients with severe renal failure. In patients with normal or moderate renal function PTAs ≥ 90% were only obtained up to MICs ≤ 8 mg/L with short infusions. However, simulating continuous infusion, higher probabilities of success were obtained against MICs of 32 and 16 mg/L when CLCR was 50 and 100 mL/min, respectively. CONCLUSIONS Population pharmacokinetic models have been developed and validated for piperacillin and tazobactam. Based on the pharmacokinetic/pharmacodynamic analysis, dosing recommendations are given considering the residual renal function of the patient and the MIC for the isolated bacteria.
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Affiliation(s)
- Eduardo Asín-Prieto
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
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50
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Abstract
An acute osteoarticular infection in a child is most often hematogenous. The infection manifests as osteomyelitis or septic arthritis. The most common causative organism is Staphylococcus aureus. Medical advice is usually sought within 2 to 6 days from the onset of symptoms. A child with an osteomyelitis in a lower extremity characteristically presents with limping with or without notable local tenderness, whereas acute septic arthritis is often readily visible because the joint is red, tender, and swollen. Early diagnosis and prompt treatment remain pivotal in avoiding complications in acute bacterial bone and joint infections.
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Affiliation(s)
- Markus Pääkkönen
- Department of Orthopaedics and Traumatology, Turku University Hospital, University of Turku, Turku 20521, Finland.
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