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Hong LT, Downes KJ, FakhriRavari A, Abdul-Mutakabbir JC, Kuti JL, Jorgensen S, Young DC, Alshaer MH, Bassetti M, Bonomo RA, Gilchrist M, Jang SM, Lodise T, Roberts JA, Tängdén T, Zuppa A, Scheetz MH. International consensus recommendations for the use of prolonged-infusion beta-lactam antibiotics: Endorsed by the American College of Clinical Pharmacy, British Society for Antimicrobial Chemotherapy, Cystic Fibrosis Foundation, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, Society of Critical Care Medicine, and Society of Infectious Diseases Pharmacists. Pharmacotherapy 2023; 43:740-777. [PMID: 37615245 DOI: 10.1002/phar.2842] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/15/2022] [Accepted: 12/26/2022] [Indexed: 08/25/2023]
Abstract
Intravenous β-lactam antibiotics remain a cornerstone in the management of bacterial infections due to their broad spectrum of activity and excellent tolerability. β-lactams are well established to display time-dependent bactericidal activity, where reductions in bacterial burden are directly associated with the time that free drug concentrations remain above the minimum inhibitory concentration (MIC) of the pathogen during the dosing interval. In an effort to take advantage of these bactericidal characteristics, prolonged (extended and continuous) infusions (PIs) can be applied during the administration of intravenous β-lactams to increase time above the MIC. PI dosing regimens have been implemented worldwide, but implementation is inconsistent. We report consensus therapeutic recommendations for the use of PI β-lactams developed by an expert international panel with representation from clinical pharmacy and medicine. This consensus guideline provides recommendations regarding pharmacokinetic and pharmacodynamic targets, therapeutic drug-monitoring considerations, and the use of PI β-lactam therapy in the following patient populations: severely ill and nonseverely ill adult patients, pediatric patients, and obese patients. These recommendations provide the first consensus guidance for the use of β-lactam therapy administered as PIs and have been reviewed and endorsed by the American College of Clinical Pharmacy (ACCP), the British Society for Antimicrobial Chemotherapy (BSAC), the Cystic Fibrosis Foundation (CFF), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the Infectious Diseases Society of America (IDSA), the Society of Critical Care Medicine (SCCM), and the Society of Infectious Diseases Pharmacists (SIDP).
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Affiliation(s)
- Lisa T Hong
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Kevin J Downes
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Jacinda C Abdul-Mutakabbir
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
- Divisions of Clinical Pharmacy and Black Diaspora and African American Studies, University of California San Diego, La Jolla, California, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | | | - David C Young
- University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | | | | | - Robert A Bonomo
- Cleveland Veteran Affairs Medical Center, Cleveland, Ohio, USA
- Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, Ohio, USA
| | - Mark Gilchrist
- Imperial College Healthcare National Health Services Trust, London, UK
| | - Soo Min Jang
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Center for Clinical Research, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marc H Scheetz
- College of Pharmacy, Pharmacometric Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
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2
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Rafailidis PI, Falagas ME. Benefits of prolonged infusion of beta-lactam antibiotics in patients with sepsis: personal perspectives. Expert Rev Anti Infect Ther 2020; 18:957-966. [PMID: 32564641 DOI: 10.1080/14787210.2020.1776113] [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: 10/24/2022]
Abstract
INTRODUCTION In the current era of relatively scarce antibiotic production and significant levels of antimicrobial resistance, optimization of pharmacokinetics and pharmacodynamics of antibiotic therapy is mandatory. Prolonged infusion of beta-lactam antibiotics in comparison to the intermittent infusion has the theoretical advantage of better patient outcomes. Apparently, conflicting data in the literature possibly underestimate the benefits of prolonged infusion of antibiotic treatment. AREAS COVERED We provide our perspective on the subject based on our experience and by critically evaluating literature data. EXPERT OPINION COMMENTARY In our opinion, the available data are suggestive of the beneficial role of prolonged infusion of beta-lactams in regard to piperacillin/tazobactam and carbapenems after administering a loading dose. While more data from randomized controlled trials are necessary to solidify or negate the evident benefits of prolonged infusion of the aforementioned antibiotics, clinicians should strongly consider this mode of administration of relevant antibiotics, especially in patients with severe infections.
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Affiliation(s)
- Petros I Rafailidis
- School of Medicine, Democritus University of Thrace , Alexandroupolis, Greece.,Alfa Institute of Biomedical Sciences (AIBS) , Athens, Greece
| | - Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS) , Athens, Greece.,Department of Internal Medicine - Infectious Diseases, Henry Dunant Hospital Center , Athens, Greece.,Department of Medicine, Tufts University School of Medicine , Boston, MA, USA
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Vardakas KZ, Voulgaris GL, Maliaros A, Samonis G, Falagas ME. Prolonged versus short-term intravenous infusion of antipseudomonal β-lactams for patients with sepsis: a systematic review and meta-analysis of randomised trials. THE LANCET. INFECTIOUS DISEASES 2018; 18:108-120. [DOI: 10.1016/s1473-3099(17)30615-1] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/07/2017] [Accepted: 09/25/2017] [Indexed: 12/13/2022]
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Roberts JA, Abdul-Aziz MH, Davis JS, Dulhunty JM, Cotta MO, Myburgh J, Bellomo R, Lipman J. Continuous versus Intermittent β-Lactam Infusion in Severe Sepsis. A Meta-analysis of Individual Patient Data from Randomized Trials. Am J Respir Crit Care Med 2017; 194:681-91. [PMID: 26974879 DOI: 10.1164/rccm.201601-0024oc] [Citation(s) in RCA: 241] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
RATIONALE Optimization of β-lactam antibiotic dosing for critically ill patients is an intervention that may improve outcomes in severe sepsis. OBJECTIVES In this individual patient data meta-analysis of critically ill patients with severe sepsis, we aimed to compare clinical outcomes of those treated with continuous versus intermittent infusion of β-lactam antibiotics. METHODS We identified relevant randomized controlled trials comparing continuous versus intermittent infusion of β-lactam antibiotics in critically ill patients with severe sepsis. We assessed the quality of the studies according to four criteria. We combined individual patient data from studies and assessed data integrity for common baseline demographics and study endpoints, including hospital mortality censored at 30 days and clinical cure. We then determined the pooled estimates of effect and investigated factors associated with hospital mortality in multivariable analysis. MEASUREMENTS AND MAIN RESULTS We identified three randomized controlled trials in which researchers recruited a total of 632 patients with severe sepsis. The two groups were well balanced in terms of age, sex, and illness severity. The rates of hospital mortality and clinical cure for the continuous versus intermittent infusion groups were 19.6% versus 26.3% (relative risk, 0.74; 95% confidence interval, 0.56-1.00; P = 0.045) and 55.4% versus 46.3% (relative risk, 1.20; 95% confidence interval, 1.03-1.40; P = 0.021), respectively. In a multivariable model, intermittent β-lactam administration, higher Acute Physiology and Chronic Health Evaluation II score, use of renal replacement therapy, and infection by nonfermenting gram-negative bacilli were significantly associated with hospital mortality. Continuous β-lactam administration was not independently associated with clinical cure. CONCLUSIONS Compared with intermittent dosing, administration of β-lactam antibiotics by continuous infusion in critically ill patients with severe sepsis is associated with decreased hospital mortality.
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Affiliation(s)
- Jason A Roberts
- 1 Department of Intensive Care Medicine and.,3 Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.,2 Burns, Trauma & Critical Care Research Centre and.,4 School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Mohd-Hafiz Abdul-Aziz
- 2 Burns, Trauma & Critical Care Research Centre and.,5 School of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Joshua S Davis
- 6 Menzies School of Health Research, Charles Darwin University, Darwin, Australia.,7 Department of Infectious Diseases, John Hunter Hospital, Newcastle, Australia
| | - Joel M Dulhunty
- 1 Department of Intensive Care Medicine and.,2 Burns, Trauma & Critical Care Research Centre and.,8 Redcliffe Hospital, Brisbane, Australia
| | - Menino O Cotta
- 1 Department of Intensive Care Medicine and.,3 Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Australia.,2 Burns, Trauma & Critical Care Research Centre and.,4 School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - John Myburgh
- 9 Critical Care and Trauma Division, The George Institute for Global Health, Sydney, Australia.,10 St. George Clinical School, University of New South Wales, Sydney, Australia
| | - Rinaldo Bellomo
- 11 Department of Intensive Care, Austin Hospital, Melbourne, Australia; and.,12 Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Jeffrey Lipman
- 1 Department of Intensive Care Medicine and.,2 Burns, Trauma & Critical Care Research Centre and
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Delattre IK, Taccone FS, Jacobs F, Hites M, Dugernier T, Spapen H, Laterre PF, Wallemacq PE, Van Bambeke F, Tulkens PM. Optimizing β-lactams treatment in critically-ill patients using pharmacokinetics/pharmacodynamics targets: are first conventional doses effective? Expert Rev Anti Infect Ther 2017; 15:677-688. [PMID: 28571493 DOI: 10.1080/14787210.2017.1338139] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The pharmacokinetic/pharmacodynamic index determining β-lactam activity is the percentage of the dosing interval (%T) during which their free serum concentration remains above a critical threshold over the minimum inhibitory concentration (MIC). Regrettably, neither the value of %T nor that of the threshold are clearly defined for critically-ill patients. Areas covered: We review and assess the targets proposed for β-lactams in critical illness by screening the literature since 1997. Depending on the study intention (clinical cure vs. suppression of resistance), targets proposed range from 20%T > 1xMIC to 100%T > 5xMIC. Assessment and comparative analysis of their respective clinical efficacy suggest that a value of 100%T > 4xMIC may be needed. Simulation studies, however, show that this target will not be reached at first dose for the majority of critically-ill patients if using the most commonly recommended doses. Expert commentary: Considering that critically-ill patients are highly vulnerable and likely to experience antibiotic underexposure, and because effective initial treatment is a key determinant of clinical outcome, we support the use of a target of 100%T > 4xMIC, which could not only maximize efficacy but also minimize emergence of resistance. Clinical and microbiological studies are needed to test for the feasibility and effectiveness of reaching such a demanding target.
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Affiliation(s)
- Isabelle K Delattre
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium.,b Department of Clinical Chemistry , Cliniques Universitaires St-Luc , Brussels , Belgium
| | - Fabio S Taccone
- c Department of Intensive Care , Hôpital Erasme , Brussels , Belgium
| | - Frédérique Jacobs
- d Department of Infectious Diseases , Hôpital Erasme , Brussels , Belgium
| | - Maya Hites
- d Department of Infectious Diseases , Hôpital Erasme , Brussels , Belgium
| | - Thierry Dugernier
- e Department of Intensive Care , Clinique St-Pierre , Ottignies , Belgium
| | - Herbert Spapen
- f Department of Intensive Care , Universitair Ziekenhuis Brussel , Brussels , Belgium
| | | | - Pierre E Wallemacq
- b Department of Clinical Chemistry , Cliniques Universitaires St-Luc , Brussels , Belgium
| | - Françoise Van Bambeke
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium
| | - Paul M Tulkens
- a Louvain Drug Research Institute , Université catholique de Louvain , Brussels , Belgium
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Dunkel B, Corley KTT. Pathophysiology, diagnosis and treatment of neonatal sepsis. EQUINE VET EDUC 2014. [DOI: 10.1111/eve.12234] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- B. Dunkel
- Department of Clinical Science and Services; Equine Referral Hospital; The Royal Veterinary College; North Mymms UK
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Korbila IP, Tansarli GS, Karageorgopoulos DE, Vardakas KZ, Falagas ME. Extended or continuous versus short-term intravenous infusion of cephalosporins: a meta-analysis. Expert Rev Anti Infect Ther 2014; 11:585-95. [DOI: 10.1586/eri.13.44] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Chant C, Leung A, Friedrich JO. Optimal dosing of antibiotics in critically ill patients by using continuous/extended infusions: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R279. [PMID: 24289230 PMCID: PMC4056781 DOI: 10.1186/cc13134] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 11/13/2013] [Indexed: 01/07/2023]
Abstract
Introduction The aim of this study was to determine whether using pharmacodynamic-based dosing of antimicrobials, such as extended/continuous infusions, in critically ill patients is associated with improved outcomes as compared with traditional dosing methods. Methods We searched Medline, HealthStar, EMBASE, Cochrane Clinical Trial Registry, and CINAHL from inception to September 2013 without language restrictions for studies comparing the use of extended/continuous infusions with traditional dosing. Two authors independently selected studies, extracted data on methodology and outcomes, and performed quality assessment. Meta-analyses were performed by using random-effects models. Results Of 1,319 citations, 13 randomized controlled trials (RCTs) (n = 782 patients) and 13 cohort studies (n = 2,117 patients) met the inclusion criteria. Compared with traditional non-pharmacodynamic-based dosing, RCTs of continuous/extended infusions significantly reduced clinical failure rates (relative risk (RR) 0.68; 95% confidence interval (CI) 0.49 to 0.94, P = 0.02) and intensive care unit length of stay (mean difference, −1.5; 95% CI, −2.8 to −0.2 days, P = 0.02), but not mortality (RR, 0.87; 95% CI, 0.64 to 1.19; P = 0.38). No significant between-trial heterogeneity was found for these analyses (I2 = 0). Reduced mortality rates almost achieved statistical significance when the results of all included studies (RCTs and cohort studies) were pooled (RR, 0.83; 95% CI, 0.69 to 1.00; P = 0.054). Conclusions Pooled results from small RCTs suggest reduced clinical failure rates and intensive care unit length-of-stay when using continuous/extended infusions of antibiotics in critically ill patients. Reduced mortality rates almost achieved statistical significance when the results of RCTs were combined with cohort studies. These results support the conduct of adequately powered RCTs to define better the utility of continuous/extended infusions in the era of antibiotic resistance.
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Shiu JR, Wang E, Tejani AM, Wasdell M. Continuous versus intermittent infusions of antibiotics for the treatment of severe acute infections. Cochrane Database Syst Rev 2013; 2013:CD008481. [PMID: 23543565 PMCID: PMC8946287 DOI: 10.1002/14651858.cd008481.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Intravenous broad-spectrum antibiotics are indicated for the treatment of severe infections. However, the emergence of infections caused by multi-drug resistant organisms in conjunction with a lack of novel antibiotics has prompted the investigation of alternative dosing strategies to improve clinical efficacy and tolerability. To optimise pharmacokinetic and pharmacodynamic antibiotic parameters, continuous antibiotic infusions have been compared to traditional intermittent antibiotic infusions. OBJECTIVES To compare the clinical efficacy and safety of continuous intravenous administration of concentration-dependent and time-dependent antibiotics to traditional intermittent intravenous administration in adults with severe acute bacterial infections. SEARCH METHODS The following electronic databases were searched in September 2012: The Cochrane Injuries Group Specialised Register, Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S). The reference lists of all relevant material, the Internet and the trials registry www.clinicaltrials.gov for completed and ongoing trials were also searched. SELECTION CRITERIA Randomized controlled trials in adults with a bacterial infection requiring intravenous antibiotic therapy comparing continuous versus intermittent infusions of antibiotics were included. Both time-dependent and concentration-dependent antibiotics were considered. DATA COLLECTION AND ANALYSIS Three independent authors performed data extraction for the included studies. All data was cross-checked and disagreements resolved by consensus. An intention to treat analysis was conducted using a random-effects model. MAIN RESULTS Twenty-nine studies met inclusion criteria with a combined total of over 1,600 patients. The majority of included studies were judged to be at unclear or high risk of bias with regard to randomisation sequence generation, allocation concealment, blinding, management of incomplete outcome data, selective outcome reporting, and other potential threats to validity. No studies were judged to be at low risk of bias for all methodological quality items assessed. There were no differences in all-cause mortality (n=1241, RR 0.89, 95% CI 0.67 - 1.20, p=0.45), infection recurrence (n=398, RR 1.22, 95% CI 0.35 - 4.19, p=0.76), clinical cure (n=975, RR 1.00, 95% CI 0.93 - 1.08, p=0.98), and superinfection post-therapy (n=813, RR 1.08, 95% CI 0.60 - 1.94, p=0.79). There were no differences in safety outcomes including adverse events (n=575, RR 1.02, 95% CI 0.94 - 1.12, p=0.63), serious adverse events (n=871, RR 1.36, 95% CI 0.80 - 2.30, p=0.26), and withdrawal due to adverse events (n=871, RR 2.03, 95% CI 0.52 - 7.95, p=0.31). A difference was observed in the subgroup analyses of clinical cure in septic versus non-septic patients, where intermittent antibiotic infusions were favoured for clinical cure in septic patients. However, this effect was not consistent between random-effects and fixed-effects analyses. No differences were found in sensitivity analyses conducted. AUTHORS' CONCLUSIONS There were no differences in mortality, infection recurrence, clinical cure, superinfection post-therapy, and safety outcomes when comparing continuous infusions of intravenous antibiotics to traditional intermittent infusions of antibiotics. However, the wide confidence intervals suggest that beneficial or harmful effects cannot be ruled out for all outcomes. Therefore, the current evidence is insufficient to recommend the widespread adoption of continuous infusion antibiotics in the place of intermittent infusions of antibiotics. Further large prospective randomised trials, with consistent and complete reporting of clinical outcome measures, conducted with concurrent pharmacokinetic and pharmacodynamic studies in special populations are required to determine whether adoption of continuous antibiotic infusions is warranted in specific circumstances.
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Affiliation(s)
| | - Erica Wang
- Interior Health AuthorityKelowna General HospitalKelownaCanada
| | - Aaron M Tejani
- University of British ColumbiaTherapeutics Initiative2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
| | - Michael Wasdell
- Bridgepoint Collaboratory for Research and Innovation Bridgepoint Health14 St. Matthews RoadTorontoCanadaON M4M 2B5
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A systematic review on clinical benefits of continuous administration of β-lactam antibiotics*. Crit Care Med 2009; 37:2071-8. [PMID: 19384201 DOI: 10.1097/ccm.0b013e3181a0054d] [Citation(s) in RCA: 190] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Boutoille D, Jacqueline C, Le Mabecque V, Potel G, Caillon J. In vivo impact of the MexAB-OprM efflux system on β-lactam efficacy in an experimental model of Pseudomonas aeruginosa infection. Int J Antimicrob Agents 2009; 33:417-20. [DOI: 10.1016/j.ijantimicag.2008.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 09/24/2008] [Accepted: 10/29/2008] [Indexed: 10/21/2022]
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Croisier D, Martha B, Piroth L, Chavanet P. In vivo efficacy of humanised intermittent versus continuous ceftazidime in combination with tobramycin in an experimental model of pseudomonal pneumonia. Int J Antimicrob Agents 2008; 32:494-8. [DOI: 10.1016/j.ijantimicag.2008.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 07/10/2008] [Accepted: 07/11/2008] [Indexed: 11/25/2022]
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Soy D, Torres A. Antibacterial dosage in intensive-care-unit patients based on pharmacokinetic/pharmacodynamic principles. Curr Opin Crit Care 2007; 12:477-82. [PMID: 16943729 DOI: 10.1097/01.ccx.0000244130.77365.c2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Selection of the best antibiotic dosage regimen in intensive-care-unit patients is a critical factor for decreasing morbidity and mortality rates. The integration of pharmacokinetics and pharmacodynamics is essential to establishing an adequate therapy. Many studies on this issue have been published in recent years due to its relevance, some of which are commented upon in this review. RECENT FINDINGS Several studies have shown that it is feasible to theoretically forecast pharmacodynamic outcomes and select the most adequate antibiotic therapy with Monte Carlo simulations. Moreover, new strategies such as the use of continuous or extended intravenous beta-lactam infusions may considerably improve therapeutic efficacy. SUMMARY Future studies are needed in patients to assess the influence of selecting antibiotic therapy based on the impact of pharmacokinetic/pharmacodynamic on mortality, morbidity, cost, etc. It would be of special interest to evaluate this impact on patients with infections caused by multiresistant pathogens, whose mortality rates are even higher. Moreover, although studies such as this would not be easy, mainly due to the large number of patients required to obtain statistically significant results, they should be strongly encouraged because of the possible clinical and economic benefits.
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Affiliation(s)
- Dolors Soy
- Pharmacy Service (UASP), Hospital Clinic Barcelona, IDIBAPS, Universitat de Barcelona, Spain.
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López E, Soy D, Miana MT, Codina C, Ribas J. Algunas reflexiones acerca de la administración de antibióticos betalactámicos en infusión continua. Enferm Infecc Microbiol Clin 2006; 24:445-52. [PMID: 16956534 DOI: 10.1157/13091783] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Numerous studies on continuous intravenous infusion of betalactam antibiotics have indicated that this could be a useful strategy for treating nosocomial infections as well as exacerbations of pulmonary infections in patients with cystic fibrosis and episodes of febrile neutropenia. From the pharmacodynamic viewpoint, betalactam antibiotics have a time-dependent behavior. Thus, the pharmacokinetic/pharmacodynamic index that best correlates with therapeutic efficacy appears to be the time during which free antibiotic concentrations remain above the minimum inhibitory concentration (MIC) of the infecting microorganism. Continuous infusion of betalactams successfully optimizes this pharmacokinetic/ pharmacodynamic index. Furthermore, some studies have shown that this therapeutic strategy may be favorable economically.
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Affiliation(s)
- Ester López
- Servicio de Farmacia del Hospital Clínic de Barcelona. España.
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