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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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Carbapenem Combinations for Infections Caused by Carbapenemase-Producing Pseudomonas aeruginosa: Experimental In Vitro and In Vivo Analysis. Antibiotics (Basel) 2022; 11:antibiotics11091212. [PMID: 36139991 PMCID: PMC9495166 DOI: 10.3390/antibiotics11091212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
Abstract
In the context of difficult-to-treat carbapenem-resistant Pseudomonas aeruginosa infections, we evaluated imipenem, meropenem, and doripenem combinations against eleven carbapenemase-producing P. aeruginosa isolates. According to the widespread global distribution of high-risk clones and carbapenemases, four representative isolates were selected: ST175 (OXA-2/VIM-20), ST175 (VIM-2), ST235 (GES-5), and ST111 (IMP-33), for efficacy studies using a sepsis murine model. Minimum inhibitory concentration (mg/L) ranges were 64–256 for imipenem and 16–128 for meropenem and doripenem. In vitro, imipenem plus meropenem was synergistic against 72% of isolates and doripenem plus meropenem or imipenem against 55% and 45%, respectively. All combinations were synergistic against the ST175, ST235, and ST155 clones. In vivo, meropenem diminished the spleen and blood bacterial concentrations of four and three isolates, respectively, with better efficacy than imipenem or doripenem. The combinations did not show efficacy compared with the more active monotherapies, except for imipenem plus meropenem, which reduced the ST235 bacterial spleen concentration. Mortality decreased with imipenem plus meropenem or doripenem for the ST175 isolate. Results suggest that carbapenem combinations are not an alternative for severe infections by carbapenemase-producing P. aeruginosa. Meropenem monotherapy showed in vivo efficacy despite its high MIC, probably because its dosage allowed a sufficient antimicrobial exposure at the infection sites.
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Liu WD, Shih MC, Chuang YC, Wang JT, Sheng WH. Comparative efficacy of doripenem versus meropenem for hospital-acquired and ventilator-associated pneumonia. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2019; 52:788-795. [PMID: 31155463 DOI: 10.1016/j.jmii.2019.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/15/2019] [Accepted: 04/19/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Doripenem shows good in vitro activity against common nosocomial pathogens, such as extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii. However, the use of doripenem for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remains controversial. The aim of this study was to compare the efficacy and safety between doripenem and meropenem for patients with HAP or VAP. METHODS Adult patients diagnosed with HAP and VAP at National Taiwan University Hospital, who received doripenem or meropenem for more than 48 h between January 2015 and November 2017, were retrospectively reviewed. All-cause mortality on the 30th day was used as the primary outcome measurements. RESULTS Fifty-seven patients with doripenem and 252 patients with meropenem were analyzed. Compared to the meropenem group, the doripenem group was younger and had a higher Sequential Organ Failure Assessment (SOFA) score. Multivariable Cox regression analysis revealed that presence of solid organ malignancies (adjusted hazard ratio [AHR], 1.82; 95% CI, 1.04-3.19, p = 0.003) and SOFA score (AHR, 1.10; 95% CI, 1.03-1.17, p = 0.003) were independent factors associated with mortality. There was no survival difference of 30-day mortality between patients receiving doripenem and meropenem for HAP or VAP (log-rank p = 0.113). However, a poorer outcome was observed among patients with hematological disease in the doripenem group (log-rank p = 0.012). CONCLUSION Our results demonstrate that doripenem has similar efficacy as meropenem in HAP or VAP patients. With an aim to enhance antibiotic diversity, doripenem could be an alternative choice for patients with HAP or VAP, except for those with hematological malignancies.
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Affiliation(s)
- Wang-Da Liu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chieh Shih
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Negi A, Anand M, Singh A, Kumar A, Sahu C, Prasad KN. Assessment of Doripenem, Meropenem, and Imipenem against Respiratory Isolates of Pseudomonas aeroginosa in a Tertiary Care Hospital of North India. Indian J Crit Care Med 2017; 21:703-706. [PMID: 29142383 PMCID: PMC5672677 DOI: 10.4103/ijccm.ijccm_341_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objective: Pseudomonas aeruginosa is one of the leading pathogen causing healthcare-associated infections, particularly in immunocompromised and critically ill patients. The development of carbapenem resistance in P. aeruginosa infections is worrisome. Data specifically comparing the susceptibility of the three available carbapenems are lacking in the Indian subcontinent. Materials and Methods: We evaluated the minimum inhibitory concentrations (MICs) of the three commonly used carbapenems– imipenem, meropenem, and doripenem against, 435 P. aeruginosa isolates obtained from respiratory samples and compared their susceptibility patterns to determine the best possible carbapenem among those available that may be used in combination regimes. Results: Overall, 222 (51.0%) of isolates were susceptible to doripenem followed by imipenem 206 (47.3%) and meropenem 195 (44.8%), respectively. Two hundred and sixty-two (60.23%) strains were intermediate or resistant to at least one carbapenem. The MIC90 of all three carbapenems was >32 μg/ml while the MIC50 of meropenem was 16 μg/ml which was higher than MIC50 of both imipenem (4 μg/ml) and doripenem (2 μg/ml). Conclusion: Our study revealed that doripenem exerted better in vitro activity against the tested bacteria compared to imipenem and meropenem, but the difference was not statistically significant.
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Affiliation(s)
- Arti Negi
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mridu Anand
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Avinash Singh
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh Kumar
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Chinmoy Sahu
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kashi Nath Prasad
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Zhao M, Lepak AJ, Andes DR. Animal models in the pharmacokinetic/pharmacodynamic evaluation of antimicrobial agents. Bioorg Med Chem 2016; 24:6390-6400. [PMID: 27887963 DOI: 10.1016/j.bmc.2016.11.008] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/02/2016] [Accepted: 11/03/2016] [Indexed: 12/28/2022]
Abstract
Animal infection models in the pharmacokinetic/pharmacodynamic (PK/PD) evaluation of antimicrobial therapy serve an important role in preclinical assessments of new antibiotics, dosing optimization for those that are clinically approved, and setting or confirming susceptibility breakpoints. The goal of animal model studies is to mimic the infectious diseases seen in humans to allow for robust PK/PD studies to find the optimal drug exposures that lead to therapeutic success. The PK/PD index and target drug exposures obtained in validated animal infection models are critical components in optimizing dosing regimen design in order to maximize efficacy while minimize the cost and duration of clinical trials. This review outlines the key components in animal infection models which have been used extensively in antibiotic discovery and development including PK/PD analyses.
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Affiliation(s)
- Miao Zhao
- Institute of Antibiotics Hua-shan Hospital, Fudan University & Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, China; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexander J Lepak
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David R Andes
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; Department of Medical Microbiology and Immunology, University of Wisconsin, Madison, WI, USA; William S. Middleton Memorial VA Hospital, Madison, WI, USA.
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MIC score, a new tool to compare bacterial susceptibility to antibiotics application to the comparison of susceptibility to different penems of clinical strains of Pseudomonas aeruginosa. J Antibiot (Tokyo) 2016; 69:806-810. [PMID: 27025352 DOI: 10.1038/ja.2016.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/11/2016] [Accepted: 03/06/2016] [Indexed: 11/08/2022]
Abstract
This study aimed to compare the susceptibility to carbapenems (imipenem, meropenem and doripenem) of clinical strains of Pseudomonas aeruginosa. It also studied whether susceptibility to imipenem or meropenem could predict, reliably, susceptibility to doripenem. Pseudomonal strains were collected from respiratory specimens, half of them from cystic fibrosis patients. MICs were determined according to European Committee on Antimicrobial Susceptibility Testing recommendations. Carbapenems were compared according to the susceptible, intermediate or resistant categories. A new approach also allowed comparing these carbapenems in a 'MIC score' taking into account the differences in breakpoints between drugs. One hundred thirty-nine strains were studied. They were found to be statistically more susceptible to meropenem than to the two other drugs. However, this difference was small: less than one dilution between the agents. This study also highlighted a significant correlation between susceptibility to penems taken in pairs. However, susceptibility to imipenem or meropenem did not reliably predict susceptibility to doripenem. Despite potential differences in resistance mechanisms, the Pseudomonas aeruginosa strains showed close susceptibility to three carbapenems. This was true for both cystic fibrosis patients and others. However, there were variations between strains. That justifies MICs to be determined for each of the three penems. This might be useful in case of elevated MICs and/or for potentially difficult-to-treat infections such as pneumonia in patients with cystic fibrosis patients.
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Yatera K, Naito K, Noguchi S, Akata K, Yamasaki K, Nishida C, Kawanami T, Sakamoto N, Kido T, Ishimoto H, Mukae H. Clinical efficacy and safety of high-dose doripenem in Japanese patients with pneumonia. J Infect Chemother 2016; 22:137-42. [DOI: 10.1016/j.jiac.2015.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 11/06/2015] [Accepted: 11/25/2015] [Indexed: 10/22/2022]
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In vivo efficacy of ceftolozane against Pseudomonas aeruginosa in a rabbit experimental model of pneumonia: Comparison with ceftazidime, piperacillin/tazobactam and imipenem. Int J Antimicrob Agents 2014; 44:218-21. [DOI: 10.1016/j.ijantimicag.2014.04.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/29/2014] [Accepted: 04/30/2014] [Indexed: 11/19/2022]
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Pharmacodynamic evaluation of the intracellular activity of antibiotics towards Pseudomonas aeruginosa PAO1 in a model of THP-1 human monocytes. Antimicrob Agents Chemother 2013; 57:2310-8. [PMID: 23478951 DOI: 10.1128/aac.02609-12] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Pseudomonas aeruginosa invades epithelial and phagocytic cells, which may play an important role in the persistence of infection. We have developed a 24-h model of THP-1 monocyte infection with P. aeruginosa PAO1 in which bacteria are seen multiplying in vacuoles by electron microscopy. The model has been used to quantitatively assess antibiotic activity against intracellular and extracellular bacteria by using a pharmacodynamic approach (concentration-dependent experiments over a wide range of extracellular concentrations to calculate bacteriostatic concentrations [Cs] and maximal relative efficacies [Emax]; Hill-Langmuir equation). Using 16 antipseudomonal antibiotics (three aminoglycosides, nine β-lactams, three fluoroquinolones, and colistin), dose-response curves were found to be undistinguishable for antibiotics of the same pharmacological class if data were expressed as a function of the corresponding MICs. Extracellularly, all of the antibiotics reached a bacteriostatic effect at their MIC, and their Emax exceeded the limit of detection (-4.5 log(10) CFU compared to the initial inoculum). Intracellularly, Cs values remained unchanged for β-lactams, fluoroquinolones, and colistin but were approximately 10 times higher for aminoglycosides, whereas Emax values were markedly reduced (less negative), reaching -3 log(10) CFU for fluoroquinolones and only -1 to -1.5 log(10) CFU for all other antibiotics. The decrease in intracellular aminoglycoside potency (higher Cs) can be ascribed to the acid pH to which bacteria are exposed in vacuoles. The decrease in the Emax may reflect a reversible alteration of bacterial responsiveness to antibiotics in the intracellular milieu. The model may prove useful for comparison of antipseudomonal antibiotics to reduce the risk of persistence or relapse of pseudomonal infections.
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Comparative pharmacodynamics and antimutant potentials of doripenem and imipenem with ciprofloxacin-resistant Pseudomonas aeruginosa in an in vitro model. Antimicrob Agents Chemother 2011; 56:1223-8. [PMID: 22203591 DOI: 10.1128/aac.05964-11] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To compare the antipseudomonal efficacy of doripenem and imipenem as well as their abilities to restrict the enrichment of resistant Pseudomonas aeruginosa, multiple-dosing regimens of each drug were simulated at comparable values of the cumulative percentages of a 24-h period that the drug concentration exceeds the MIC under steady-state pharmacokinetic conditions (T(>MIC)) and ratios of the 24-hour area under the curve (AUC(24)) to the MIC. Three clinical isolates of ciprofloxacin-resistant P. aeruginosa (MIC of doripenem, 1 μg/ml; MICs of imipenem, 1, 2, and 2 μg/ml) were exposed to thrice-daily doripenem or imipenem for 3 days at AUC(24)/MIC ratios of from 50 to 170 h (doripenem) and from 30 to 140 h (imipenem). The antimicrobial effects for susceptible and resistant subpopulations of bacteria were expressed by the areas between control growth and time-kill curves (I(E)s) and areas under the bacterial mutant concentration curves (AUBC(M)s), respectively. With each antibiotic, the I(E) and AUBC(M) versus log AUC(24)/MIC relationships were bacterial strain independent. At similar AUC(24)/MIC ratios, doripenem was slightly less efficient than imipenem against susceptible and resistant subpopulations of bacteria. However, doripenem appeared to be somewhat more efficient than imipenem at clinically achievable AUC(24)s related to the means of the MICs for the three studied strains and had higher antimutant potentials for two of the three strains.
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Bretonnière C, Jacqueline C, Caillon J, Guitton C, Desessard C, Le Mabecque V, Miégeville AF, Villers D, Potel G, Boutoille D. Evaluation of doripenem in an experimental model of resistant Pseudomonas aeruginosa pneumonia. J Antimicrob Chemother 2011; 67:780-1. [PMID: 22184470 DOI: 10.1093/jac/dkr528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Penetration of doripenem into skeletal muscle and subcutaneous adipose tissue in healthy volunteers. Antimicrob Agents Chemother 2011; 56:532-5. [PMID: 22083466 DOI: 10.1128/aac.05506-11] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Sufficient antibiotic concentrations at the infection site are a prerequisite for good bacterial killing. This study was performed to determine pharmacokinetics of doripenem in soft tissues and saliva. Six healthy male volunteers received a single intravenous infusion of 500 mg doripenem over 1 h. The concentrations of doripenem were measured over 8 h in saliva, plasma, and extracellular space fluid of skeletal muscle and subcutaneous adipose tissue employing in vivo microdialysis. Unbound drug concentrations were determined using ultra-high-performance liquid chromatography-tandem mass spectrometry. Maximum concentrations of doripenem were 15.3 ± 6.0 mg/liter in plasma, 9.9 ± 2.3 mg/liter in subcutaneous adipose tissue, 6.6 ± 2.9 mg/liter in skeletal muscle, and 0.5 ± 0.2 mg/liter in saliva. Areas under the concentration-time curve (AUC) from 0 to infinity were 26.3 ± 10.1, 20.4 ± 3.8, 12.8 ± 3.0, and 1.0 ± 0.5 mg · h/liter in plasma, adipose tissue, skeletal muscle, and saliva, respectively. Ratios of AUC in adipose tissue, skeletal muscle, and saliva to those in plasma were 0.84 ± 0.28, 0.53 ± 0.19, and 0.04 ± 0.03, respectively. In all six volunteers, a threshold of ≥40% for "time above MIC," an index indicative of good antimicrobial activity, was exceeded in adipose tissue for MICs of ≤2 mg/liter and in skeletal muscle for MICs ≤1.5 mg/liter. Doripenem penetrates well into interstitial space fluid of skeletal muscle and adipose tissue, suggesting good antimicrobial activity in infected soft tissues, whereas it is detectable in relatively low concentrations in saliva.
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