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Lalanne S, Bouzillé G, Tron C, Revest M, Polard E, Bellissant E, Verdier MC, Lemaitre F. Amoxicillin-Induced Neurotoxicity: Contribution of a Healthcare Data Warehouse to the Determination of a Toxic Concentration Threshold. Antibiotics (Basel) 2023; 12:antibiotics12040680. [PMID: 37107042 PMCID: PMC10135267 DOI: 10.3390/antibiotics12040680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Amoxicillin (AMX)-induced neurotoxicity is well described and may be associated with AMX overexposure. No neurotoxic concentration threshold has been determined thus far. A better knowledge of maximum tolerable AMX concentrations is of importance to improve the safety of high doses of AMX. Methods: We conducted a retrospective study using the local hospital data warehouse EhOP® to generate a specific query related to AMX neurotoxicity symptomatology. All patient medical reports containing a mention of neurotoxicity clinical symptoms coupled with AMX plasma concentration measurements were explored. Patients were classified into two groups according to the imputability of AMX in the onset of their neurotoxicity, on the basis of chronological and semiological criteria. A receiver-operating characteristic curve was performed to identify an AMX neurotoxic steady-state concentration (Css) threshold. Results: The query identified 101 patients among 2054 patients benefiting from AMX TDM. Patients received a median daily dose of 9 g AMX, with a median creatinine clearance of 51 mL/min. A total of 17 of the 101 patients exhibited neurotoxicity attributed to AMX. The mean Css was higher for patients with neurotoxicity attributed to AMX (118 ± 62 mg/L) than those without 74 ± 48 mg/L (p = 0.002). A threshold AMX concentration of 109.7 mg/L predicted the occurrence of neurotoxicity. Conclusions: This study identified, for the first time, an AMX Css threshold of 109.7 mg/L associated with an excess risk of neurotoxicity. This approach needs to be confirmed by a prospective study with systematic neurological evaluation and TDM.
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Affiliation(s)
- Sébastien Lalanne
- Department of Pharmacology, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche Ensanté, Environnement et Travail) UMR_S 1085, University of Rennes, 35000 Rennes, France
- Correspondence:
| | - Guillaume Bouzillé
- CHU Rennes, Inserm, LTSI—UMR 1099, University of Rennes, 35000 Rennes, France
| | - Camille Tron
- Department of Pharmacology, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche Ensanté, Environnement et Travail) UMR_S 1085, University of Rennes, 35000 Rennes, France
| | - Matthieu Revest
- CHU Rennes, Infectious Diseases and Intensive Care Unit, 2 Rue Henri Le Guilloux, University of Rennes, 35033 Rennes, France
| | - Elisabeth Polard
- Department of Pharmacology, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche Ensanté, Environnement et Travail) UMR_S 1085, University of Rennes, 35000 Rennes, France
| | - Eric Bellissant
- Department of Pharmacology, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche Ensanté, Environnement et Travail) UMR_S 1085, University of Rennes, 35000 Rennes, France
| | - Marie-Clémence Verdier
- Department of Pharmacology, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche Ensanté, Environnement et Travail) UMR_S 1085, University of Rennes, 35000 Rennes, France
| | - Florian Lemaitre
- Department of Pharmacology, CHU Rennes, Inserm, EHESP, Irset (Institut de Recherche Ensanté, Environnement et Travail) UMR_S 1085, University of Rennes, 35000 Rennes, France
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Stašek J, Keller F, Kočí V, Klučka J, Klabusayová E, Wiewiorka O, Strašilová Z, Beňovská M, Škardová M, Maláska J. Update on Therapeutic Drug Monitoring of Beta-Lactam Antibiotics in Critically Ill Patients—A Narrative Review. Antibiotics (Basel) 2023; 12:antibiotics12030568. [PMID: 36978435 PMCID: PMC10044408 DOI: 10.3390/antibiotics12030568] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023] Open
Abstract
Beta-lactam antibiotics remain one of the most preferred groups of antibiotics in critical care due to their excellent safety profiles and their activity against a wide spectrum of pathogens. The cornerstone of appropriate therapy with beta-lactams is to achieve an adequate plasmatic concentration of a given antibiotic, which is derived primarily from the minimum inhibitory concentration (MIC) of the specific pathogen. In a critically ill patient, the plasmatic levels of drugs could be affected by many significant changes in the patient’s physiology, such as hypoalbuminemia, endothelial dysfunction with the leakage of intravascular fluid into interstitial space and acute kidney injury. Predicting antibiotic concentration from models based on non-critically ill populations may be misleading. Therapeutic drug monitoring (TDM) has been shown to be effective in achieving adequate concentrations of many drugs, including beta-lactam antibiotics. Reliable methods, such as high-performance liquid chromatography, provide the accurate testing of a wide range of beta-lactam antibiotics. Long turnaround times remain the main drawback limiting their widespread use, although progress has been made recently in the implementation of different novel methods of antibiotic testing. However, whether the TDM approach can effectively improve clinically relevant patient outcomes must be proved in future clinical trials.
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Affiliation(s)
- Jan Stašek
- Department of Internal Medicine and Cardiology, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Filip Keller
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Veronika Kočí
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Eva Klabusayová
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
| | - Ondřej Wiewiorka
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Zuzana Strašilová
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Miroslava Beňovská
- Department of Laboratory Medicine, Division of Clinical Biochemistry, University Hospital Brno, 625 00 Brno, Czech Republic
- Department of Laboratory Methods, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Markéta Škardová
- Department of Clinical Pharmacy, Hospital Pharmacy, University Hospital Brno, 625 00 Brno, Czech Republic
| | - Jan Maláska
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Brno, Masaryk University, 662 63 Brno, Czech Republic
- 2nd Department of Anaesthesiology University Hospital Brno, 620 00 Brno, Czech Republic
- Correspondence:
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Smit C, Sen S, von Dach E, Karmime A, Lescuyer P, Tonoli D, Bielicki J, Huttner A, Pfister M. Steering Away from Current Amoxicillin Dose Reductions in Hospitalized Patients with Impaired Kidney Function to Avoid Subtherapeutic Drug Exposure. Antibiotics (Basel) 2022; 11:antibiotics11091190. [PMID: 36139969 PMCID: PMC9494977 DOI: 10.3390/antibiotics11091190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Current dose reductions recommended for amoxicillin in patients with impaired kidney function could lead to suboptimal treatments. In a prospective, observational study in hospitalized adults with varying kidney function treated with an IV or oral dose of amoxicillin, amoxicillin concentrations were measured in 1−2 samples on the second day of treatment. Pharmacometric modelling and simulations were performed to evaluate the probability of target attainment (PTA) for 40% of the time above MIC following standard (1000 mg q6h), reduced or increased IV dosing strategies. A total of 210 amoxicillin samples was collected from 155 patients with kidney function based on a CKD-EPI of between 12 and 165 mL/min/1.73 m2. Amoxicillin clearance could be well predicted with body weight and CKD-EPI. Recommended dose adjustments resulted in a clinically relevant reduction in the PTA for the nonspecies-related PK/PD breakpoint MIC of 8 mg/L (92%, 62% and 38% with a CKD-EPI of 10, 20 and 30 mL/min/1.73 m2, respectively, versus 100% for the standard dose). For MICs ≤ 2 mg/L, PTA > 90% was reached in these patients following both reduced and standard dose regimens. Our study showed that for amoxicillin, recommended dose reductions with impaired kidney function could lead to subtherapeutic amoxicillin concentrations in hospitalized patients, especially when targeting less susceptible pathogens.
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Affiliation(s)
- Cornelis Smit
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Department of Clinical Pharmacy, Antonius Hospital, 8601 ZK Sneek, The Netherlands
| | - Swapnoleena Sen
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland
- Swiss Tropical and Public Health Institute, 4056 Basel, Switzerland
| | - Elodie von Dach
- Center for Clinical Research, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
| | - Abderrahim Karmime
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Pierre Lescuyer
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - David Tonoli
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Julia Bielicki
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s, University of London, London SW17 0RE, UK
| | - Angela Huttner
- Center for Clinical Research, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Certara, Princeton, NJ 08540, USA
- Correspondence: ; Tel.: +41-61-704-1212
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