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Damgaard T, Woksepp H, Brudin L, Bonnedahl J, Nielsen EI, Schön T, Hällgren A. Estimated glomerular filtration rate as a tool for early identification of patients with insufficient exposure to beta-lactam antibiotics in intensive care units. Infect Dis (Lond) 2024; 56:451-459. [PMID: 38436273 DOI: 10.1080/23744235.2024.2323002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Only about 50% of intensive care unit (ICU) patients reach a free trough concentration above MIC (100% fT > MIC) of beta-lactam antibiotics. Although dose adjustments based on therapeutic drug monitoring (TDM) could be beneficial, TDM is not widely available. We investigated serum creatinine-based estimated GFR (eGFR) as a rapid screening tool to identify ICU patients at risk of insufficient exposure. METHOD Ninety-three adult patients admitted to four ICUs in southeast Sweden treated with piperacillin/tazobactam, meropenem, or cefotaxime were included. Beta-lactam trough concentrations were measured. The concentration target was set to 100% fT > MICECOFF (2, 4, and 16 mg/L based on calculated free levels for meropenem, cefotaxime, and piperacillin, respectively). eGFR was primarily determined via Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) and compared to three other eGFR equations. Data was analysed using logistic regression and receiver operative characteristic (ROC) curves. RESULTS With intermittent standard dosing, insufficient exposure was common in patients with a relative eGFR ≥48mL/min/1.73m2 [85%, (45/53)], particularly when treated with cefotaxime [96%, (24/25)]. This eGFR cut-off had a sensitivity of 92% and specificity of 82% (AUC 0.871, p < 0.001) in identifying insufficient exposure. In contrast, patients with eGFR <48mL/min/1.73m2 had high target attainment [90%, (36/40)] with a wide variability in drug exposure. There was no difference between the four eGFR equations (AUC 0.866-0.872, cut-offs 44-51 ml/min/1.73m2). CONCLUSION Serum creatinine-based eGFR is a simple and widely available surrogate marker with potential for early identification of ICU patients at risk of insufficient exposure to piperacillin, meropenem, and cefotaxime.
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Affiliation(s)
- Tobias Damgaard
- Pharmaceutical Department in Kalmar, Region Kalmar County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Hanna Woksepp
- Department of Research and Department of Clinical Microbiology in Kalmar, Region Kalmar County, and Department of Chemistry and Biomedical Sciences, Linnaeus University, Kalmar, Sweden
| | - Lars Brudin
- Department of Clinical Physiology in Kalmar, Region Kalmar County, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jonas Bonnedahl
- Department of Infectious Diseases in Kalmar, Region Kalmar County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Thomas Schön
- Department of Infectious Diseases in Kalmar, Region Kalmar County, Department of Infectious Diseases in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Anita Hällgren
- Department of Infectious Diseases in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Gatti M, Cojutti PG, Pea F. Impact of attaining aggressive vs. conservative PK/PD target on the clinical efficacy of beta-lactams for the treatment of Gram-negative infections in the critically ill patients: a systematic review and meta-analysis. Crit Care 2024; 28:123. [PMID: 38627763 PMCID: PMC11020314 DOI: 10.1186/s13054-024-04911-5] [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: 03/02/2024] [Accepted: 04/13/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND To perform a systematic review with meta-analysis with the dual intent of assessing the impact of attaining aggressive vs. conservative beta-lactams PK/PD target on the clinical efficacy for treating Gram-negative infections in critical patients, and of identifying predictive factors of failure in attaining aggressive PK/PD targets. METHODS Two authors independently searched PubMed-MEDLINE and Scopus database from inception to 23rd December 2023, to retrieve studies comparing the impact of attaining aggressive vs. conservative PK/PD targets on clinical efficacy of beta-lactams. Independent predictive factors of failure in attaining aggressive PK/PD targets were also assessed. Aggressive PK/PD target was considered a100%fT>4xMIC, and clinical cure rate was selected as primary outcome. Meta-analysis was performed by pooling odds ratios (ORs) extrapolated from studies providing adjustment for confounders using a random-effects model with inverse variance method. RESULTS A total of 20,364 articles were screened, and 21 observational studies were included in the meta-analysis (N = 4833; 2193 aggressive vs. 2640 conservative PK/PD target). Attaining aggressive PK/PD target was significantly associated with higher clinical cure rate (OR 1.69; 95% CI 1.15-2.49) and lower risk of beta-lactam resistance development (OR 0.06; 95% CI 0.01-0.29). Male gender, body mass index > 30 kg/m2, augmented renal clearance and MIC above the clinical breakpoint emerged as significant independent predictors of failure in attaining aggressive PK/PD targets, whereas prolonged/continuous infusion administration of beta-lactams resulted as protective factor. The risk of bias was moderate in 19 studies and severe in the other 2. CONCLUSIONS Attaining aggressive beta-lactams PK/PD targets provided significant clinical benefits in critical patients. Our analysis could be useful to stratify patients at high-risk of failure in attaining aggressive PK/PD targets.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy.
| | - Pier Giorgio Cojutti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138, Bologna, Italy
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Wu Y, Lu Z, Liang P, Zhu H, Qi H, Zhang H. Relationship of imipenem therapeutic drug monitoring to clinical outcomes in critically ill patients: a retrospective cohort study. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023:10.1007/s00210-023-02909-4. [PMID: 38153513 DOI: 10.1007/s00210-023-02909-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/14/2023] [Indexed: 12/29/2023]
Abstract
The primary objective of this study was to evaluate the predictors associated with target concentration (non-)attainment of imipenem in critically ill patients. The secondary objective was to explore the correlation between achieving imipenem target concentrations and clinical outcomes of therapy. A retrospective cohort study was conducted in critically ill patients treated with imipenem. Clinical data were extracted from the patients' electronic medical records. The pharmacokinetic/pharmacodynamic target was defined as free imipenem concentrations above the minimum inhibitory concentration (MIC) of the pathogen at 100% (100%fT>MIC) of the dosing interval. Factors associated with the non-attainment of target concentrations were evaluated using binomial logistic regression. Kaplan-Meier analysis was used to investigate the correlation between (non-)attainment targets and 30-day mortality. A total of 406 patients were included, and 55.4% achieved the target of 100%fT>MIC. Regression analysis identified an initial daily dose of imipenem ≤ 2 g/day, augmented renal clearance, age ≤ 60 years, recent surgery, and absence of positive microbiology culture as risk factors for target non-attainment. Achieving the 100%fT>MIC target was significantly associated with clinical efficacy but not with 30-day mortality. Selective application of therapeutic drug monitoring in the early stages of imipenem treatment for critically ill patients can improve clinical outcomes. Further research should explore the potential benefits of TDM-guided dosing strategies for imipenem in critical care settings.
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Affiliation(s)
- Yejing Wu
- Department of Pharmacy, Nanjing Drum Tower Hospital, Traditional Chinese and Western Medicine Clinical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhangyang Lu
- Department of Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Pei Liang
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Huaijun Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China
| | - Hui Qi
- Department of Intensive Care Unit, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Haixia Zhang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Traditional Chinese and Western Medicine Clinical College, Nanjing University of Chinese Medicine, Nanjing, China.
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
- Nanjing Medical Center for Clinical Pharmacy, Nanjing, China.
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Contejean A, Maillard A, Canouï E, Kernéis S, Fantin B, Bouscary D, Parize P, Garcia-Vidal C, Charlier C. Advances in antibacterial treatment of adults with high-risk febrile neutropenia. J Antimicrob Chemother 2023; 78:2109-2120. [PMID: 37259598 DOI: 10.1093/jac/dkad166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND High-risk febrile neutropenia (HR-FN) is a life-threatening complication in patients with haematological malignancies or receiving myelosuppressive chemotherapy. Since the last international guidelines were published over 10 years ago, there have been major advances in the understanding and management of HR-FN, including on antibiotic pharmacokinetics and discontinuation/de-escalation strategies. OBJECTIVES Summarizing major advances in the field of antibacterial therapy in patients with HR-FN: empirical therapy, pharmacokinetics of antibiotics and antibiotic stewardship. SOURCES Narrative review based on literature review from PubMed. We focused on studies published between 2010 and 2023 about the pharmacokinetics of antimicrobials, management of antimicrobial administration, and discontinuation/de-escalation strategies. We did not address antimicrobial prophylaxis, viral or fungal infections. CONTENT Several high-quality publications have highlighted important modifications of antibiotic pharmacokinetics in HR-FN, with standard dosages exposing patients to underdosing. These recent clinical and population pharmacokinetics studies help improve management protocols with optimized initial dosing and infusion rules for β-lactams, vancomycin, daptomycin and amikacin; they highlight the potential benefits of therapeutic drug monitoring. A growing body of evidence also shows that antibiotic discontinuation/de-escalation strategies are beneficial for bacterial ecology and patients' outcome. We further discuss methods and limitations for implementation of such protocols in haematology. IMPLICATIONS We highlight recent information about the management of antibacterial therapy in HR-FN that might be considered in updated guidelines for HR-FN management.
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Affiliation(s)
- Adrien Contejean
- Service d'Hématologie, Centre Hospitalier Annecy Genevois, 1 Avenue de l'hôpital, F-74370 Epagny Metz-Tessy, France
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
| | - Alexis Maillard
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Etienne Canouï
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Solen Kernéis
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Équipe de Prévention du Risque Infectieux, AP-HP, Hôpital Bichat, F-75018 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
| | - Bruno Fantin
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Département de Médecine Interne, AP-HP, Hôpital Beaujon, F-92110, Clichy, France
| | - Didier Bouscary
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Service d'Hématologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Perrine Parize
- Service de Maladies Infectieuses, AP-HP, APHP.CUP, Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- CIBERINF, Madrid, Spain
| | - Caroline Charlier
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- National Reference Center Listeriosis WHO Collaborating Center, Institut Pasteur, F-75015 Paris, France
- Biology of Infection Unit, Inserm U1117 Institut Pasteur, F-75015 Paris, France
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Gorham J, Taccone FS, Hites M. Therapeutic Drug Monitoring of Antimicrobials in Critically Ill Obese Patients. Antibiotics (Basel) 2023; 12:1099. [PMID: 37508195 PMCID: PMC10376599 DOI: 10.3390/antibiotics12071099] [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: 05/10/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Obesity is a significant global public health concern that is associated with an elevated risk of comorbidities as well as severe postoperative and nosocomial infections. The treatment of infections in critically ill obese patients can be challenging because obesity affects the pharmacokinetics and pharmacodynamics of antibiotics, leading to an increased risk of antibiotic therapy failure and toxicity due to inappropriate dosages. Precision dosing of antibiotics using therapeutic drug monitoring may help to improve the management of this patient population. This narrative review outlines the pharmacokinetic and pharmacodynamic changes that result from obesity and provides a comprehensive critical review of the current available data on dosage adjustment of antibiotics in critically ill obese patients.
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Affiliation(s)
- Julie Gorham
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious Diseases, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
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Effectiveness and Safety of Beta-Lactam Antibiotics with and without Therapeutic Drug Monitoring in Patients with Pseudomonas aeruginosa Pneumonia or Bloodstream Infection. Antimicrob Agents Chemother 2022; 66:e0064622. [PMID: 36073943 PMCID: PMC9578394 DOI: 10.1128/aac.00646-22] [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: 11/20/2022] Open
Abstract
This objective of this study was to compare clinical outcomes in hospitalized patients with Pseudomonas aeruginosa pneumonia (PNA) or bloodstream infection (BSI) receiving beta-lactam antibiotic (BLA) infusions with and without the guidance of therapeutic drug monitoring (TDM). A retrospective, parallel cohort study was conducted at two academic medical centers between December 2015 and January 2020, UF Shands Gainesville, which uses BLA TDM for select patients (BLA TDM), and UF Health Jacksonville, which does not use BLA TDM (No-BLA TDM). All hospitalized adult patients with respiratory or blood culture positive for P. aeruginosa who met diagnosis criteria for lower respiratory tract infection with a positive P. aeruginosa respiratory culture and who received ≥48 h of intravenous BLA with in vitro susceptibility within 72 h of positive culture collection were included. The primary outcome was a composite of presumed treatment failure defined as the presence of any of the following from index-positive P. aeruginosa culture collection to the end of BLA therapy: all-cause mortality, escalation of and/or additional antimicrobial therapy for P. aeruginosa infection after 48 h of treatment with susceptible BLA due to worsening clinical status, or transfer to a higher level of care (i.e., the intensive care unit [ICU]). Analyses were adjusted for possible confounding with inverse probability of treatment weighting (IPTW). Two-hundred patients were included (BLA TDM, n = 95; No-BLA TDM, n = 105). In IPTW-adjusted analysis of the primary composite endpoint, BLA TDM demonstrated a significant decrease in presumed treatment failure compared to No-BLA TDM (adjusted odds ratio [aOR] 0.037, 95% confidence interval [CI] [0.013 to 0.107]; P < 0.001). BLA TDM had more 30-, 60- and 90-day infection-related readmissions ([aOR], 11.301, 95% CI (3.595 to 35.516); aOR 10.389, 95% CI [2.496 to 43.239], and aOR 24.970, 95% CI [6.703 to 93.028]) in IPTW analyses. For both unadjusted and IPTW-adjusted cohorts, there was no significant difference in hospital and ICU length of stay, adverse effects while on BLA, or microbiological eradication between BLA TDM and No-BLA TDM. In hospitalized adult patients with P. aeruginosa PNA or BSI, the use of TDM-guided BLA infusions decreased the odds of presumed treatment failure compared to patients receiving BLA infusions without TDM guidance. Future studies should evaluate BLA TDM impact on readmission.
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Gorham J, Taccone FS, Hites M. Ensuring target concentrations of antibiotics in critically ill patients through dose adjustment. Expert Opin Drug Metab Toxicol 2022; 18:177-187. [PMID: 35311440 DOI: 10.1080/17425255.2022.2056012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Antibiotics are commonly prescribed in critical care, and given the large variability of pharmacokinetic (PK) parameters in these patients, drug PK frequently varies during therapy with the risk of either treatment failure or toxicity. Therefore, adequate antibiotic dosing in critically ill patients is very important. AREAS COVERED This review provides an overview of the basic principles of PK and pharmacodynamics of antibiotics and the main patient and pathogen characteristics that may affect the dosage of antibiotics and different approaches to adjust doses. EXPERT OPINION Dose adjustment should be done for aminoglycosides and glycopeptides based on daily drug concentration monitoring. For glycopeptides, in particular vancomycin, the residual concentration (Cres) should be assessed daily. For beta-lactam antibiotics, a loading dose should be administered, followed by three different possible approaches, as TDM is rarely available in most centers: 1) antibiotic regimens should be adapted according to renal function and other risk factors; 2) nomograms or software can be used to calculate daily dosing; 3) TDM should be performed 24-48 h after the initiation of treatment; however, the results are required within 24 hours to appropriately adjust dosage regimens. Drug dosing should be reduced or increased according to the TDM results.
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Affiliation(s)
- Julie Gorham
- Department of intensive care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of intensive care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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8
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Maguigan KL, Al-Shaer MH, Peloquin CA. Beta-Lactams Dosing in Critically Ill Patients with Gram-Negative Bacterial Infections: A PK/PD Approach. Antibiotics (Basel) 2021; 10:1154. [PMID: 34680734 PMCID: PMC8532626 DOI: 10.3390/antibiotics10101154] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/17/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022] Open
Abstract
Beta-lactam antibiotics are often the backbone of treatment for Gram-negative infections in the critically ill. Beta-lactams exhibit time-dependent killing, and their efficacy depends on the percentage of dosing interval that the concentration remains above the minimum inhibitory concentration. The Gram-negative resistance rates of pathogens are increasing in the intensive care unit (ICU), and critically ill patients often possess physiology that makes dosing more challenging. The volume of distribution is usually increased, and drug clearance is variable. Augmented renal clearance and hypermetabolic states increase the clearance of beta-lactams, while acute kidney injury reduces the clearance. To overcome the factors affecting ICU patients and decreasing susceptibilities, dosing strategies involving higher doses, and extended or continuous infusions may be required. In this review, we specifically examined pharmacokinetic models in ICU patients, to determine the desired beta-lactam regimens for clinical breakpoints of Enterobacterales and Pseudomonas aeruginosa, as determined by the European Committee on Antimicrobial Susceptibility Testing. The beta-lactams evaluated included penicillins, cephalosporins, carbapenems, and monobactams. We found that when treating less-susceptible pathogens, especially P. aeruginosa, continuous infusions are frequently needed to achieve the desired pharmacokinetic/pharmacodynamic targets. More studies are needed to determine optimal dosing strategies in the novel beta-lactams.
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Affiliation(s)
- Kelly L. Maguigan
- Pharmacy Department, University of Florida Health Shands Hospital, Gainesville, FL 32608, USA;
| | - Mohammad H. Al-Shaer
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, College of Pharmacy and Emerging Pathogens Institute, University of Florida, Gainesville, FL 32610, USA;
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Aardema H, Bult W, van Hateren K, Dieperink W, Touw DJ, Alffenaar JWC, Zijlstra JG. Continuous versus intermittent infusion of cefotaxime in critically ill patients: a randomized controlled trial comparing plasma concentrations. J Antimicrob Chemother 2021; 75:441-448. [PMID: 31697336 DOI: 10.1093/jac/dkz463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In critical care patients, reaching optimal β-lactam concentrations poses challenges, as infections are caused more often by microorganisms associated with higher MICs, and critically ill patients typically have an unpredictable pharmacokinetic/pharmacodynamic profile. Conventional intermittent dosing frequently yields inadequate drug concentrations, while continuous dosing might result in better target attainment. Few studies address cefotaxime concentrations in this population. OBJECTIVES To assess total and unbound serum levels of cefotaxime and an active metabolite, desacetylcefotaxime, in critically ill patients treated with either continuously or intermittently dosed cefotaxime. METHODS Adult critical care patients with indication for treatment with cefotaxime were randomized to treatment with either intermittent dosing (1 g every 6 h) or continuous dosing (4 g/24 h, after a loading dose of 1 g). We defined a preset target of reaching and maintaining a total cefotaxime concentration of 4 mg/L from 1 h after start of treatment. CCMO trial registration number NL50809.042.14, Clinicaltrials.gov NCT02560207. RESULTS Twenty-nine and 30 patients, respectively, were included in the continuous dosing group and the intermittent dosing group. A total of 642 samples were available for analysis. In the continuous dosing arm, 89.3% met our preset target, compared with 50% in the intermittent dosing arm. Patients not reaching this target had a significantly higher creatinine clearance on the day of admission. CONCLUSIONS These results support the application of a continuous dosing strategy of β-lactams in critical care patients and the practice of therapeutic drug monitoring in a subset of patients with higher renal clearance and need for prolonged treatment for further optimization, where using total cefotaxime concentrations should suffice.
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Affiliation(s)
- Heleen Aardema
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
| | - Wouter Bult
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Kai van Hateren
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Willem Dieperink
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
| | - Daan J Touw
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Department of Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- University of Groningen, University Medical Center Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands.,University of Sydney, Faculty of Medicine and Health, School of Pharmacy, Sydney, Australia.,Westmead Hospital, Sydney, Australia
| | - Jan G Zijlstra
- University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, The Netherlands
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Veillette JJ, Winans SA, Maskiewicz VK, Truong J, Jones RN, Forland SC. Pharmacokinetics and Pharmacodynamics of High-Dose Piperacillin-Tazobactam in Obese Patients. Eur J Drug Metab Pharmacokinet 2021; 46:385-394. [PMID: 33743171 PMCID: PMC8093170 DOI: 10.1007/s13318-021-00677-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/09/2022]
Abstract
Background and Objective Standard piperacillin–tazobactam (P-T) dosing may be suboptimal in obesity, but high-dose regimens have not been studied. We prospectively evaluated the pharmacokinetics and pharmacodynamics of standard- and high-dose P-T in obese adult inpatients. Methods Those receiving standard-dose P-T with BMI ≥ 30 kg/m2 weighing 105–139 kg or ≥ 140 kg were given up to 6.75 g or 9 g every 6 h, respectively. Patients were monitored closely for safety. Elimination phase blood samples were drawn for 28 patients on standard and high doses to calculate the pharmacokinetic values using a one-compartment model. The likelihood of pharmacodynamic target attainment (100% fT > 16/4 mg/L) on various P-T regimens was calculated using each patient’s own pharmacokinetic values. Results Piperacillin and tazobactam half-lives ranged from 0.5–10.6 to 0.9–15.0 h, while volumes of distribution ranged from 13.6–54.8 to 11.5–60.1 L, respectively. Predicted dose requirements for target attainment ranged from 2.25 g every 6 h in hemodialysis patients to a 27 g/24-h continuous infusion in a patient with a short P-T half-life. An amount of 4.5 g every 6 h would have met the target for only 1/12 (8%) patients with creatinine clearance ≥ 80 mL/min and 13/28 (46%) for all enrolled patients. One patient (3%) experienced an adverse event deemed probably related to high-dose P-T. Conclusion Some patients required high P-T doses for target attainment, but dosing requirements were highly variable. Doses up to 6.75 g or 9 g every 6 h may be tolerable; however, studies are needed to see if high dosing, prolonged infusions, or real-time therapeutic drug monitoring improves outcomes in obese patients. Clinical trial registration (clinicaltrials.gov) NCT01923363. Supplementary Information The online version contains supplementary material available at 10.1007/s13318-021-00677-1.
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Affiliation(s)
- John J Veillette
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA.
| | - S Alexander Winans
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - Victoria K Maskiewicz
- Department of Pharmaceutical and Administrative Sciences, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | - James Truong
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | | | - Steven C Forland
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA.,Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA, USA.,Loma Linda University School of Medicine, Loma Linda, CA, USA
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Steffens NA, Zimmermann ES, Nichelle SM, Brucker N. Meropenem use and therapeutic drug monitoring in clinical practice: a literature review. J Clin Pharm Ther 2021; 46:610-621. [PMID: 33533509 DOI: 10.1111/jcpt.13369] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/01/2021] [Accepted: 01/20/2021] [Indexed: 12/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Meropenem, a carbapenem antibiotic, is widely prescribed for the treatment of life-threatening infections. The main parameter associated with its therapeutic success is the percentage of time that the levels remain above the minimum inhibitory concentration. Inadequate levels of meropenem can lead to therapeutic failure and increase the possibility of microbial resistance. The employment of strategies involving dose regimens and drug pharmacodynamics has become increasingly important to optimize therapies. In the present study, we conducted a review with the purpose of assembling information about the clinical use of meropenem and therapeutic drug monitoring. METHODS A literature review emphasizing the application of therapeutic drug monitoring (TDM) of meropenem in clinical practice has been done. To identify articles related to the topic, we performed a standardized search from January 21, 2020 to December 21, 2020, using specific descriptors in PubMed, Lilacs and Embase. RESULTS AND DISCUSSION In total, 35 studies were included in the review. The daily dose of meropenem commonly ranged from 3 to 6 g/day. Critically ill patients and those with impaired renal function appear to be the most suitable patients for the application of meropenem TDM, in order to guide therapy. We observed that most of the studies recommend TDM and that, in nine locations, the TDM of meropenem and of other beta-lactams is a routine practice. TDM data can help to maximize the clinical outcomes of the treatment with meropenem. It can also improve the patient care by providing suitable levels of meropenem, guiding the most appropriate dose regimens, which is the main parameter associated with therapeutic success. WHAT IS NEW AND CONCLUSION The findings from this review suggest that the therapeutic monitoring of meropenem can be beneficial, since it adjusts the treatment and aids clinical outcomes. It does so by indicating the appropriate dosage and preventing failure, toxicity and possible antimicrobial resistance. The multidisciplinary effort, basic knowledge and communication among the medical team are also essential.
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Affiliation(s)
- Nadine A Steffens
- Graduate Program in Pharmaceutical Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Estevan S Zimmermann
- Center for Pharmacometrics & Systems Pharmacology, College of Pharmacy, University of Florida at Lake Nona, Orlando, FL, USA
| | - Sabrina M Nichelle
- Department of Physiology and Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
| | - Natália Brucker
- Graduate Program in Pharmaceutical Sciences, Federal University of Santa Maria, Santa Maria, RS, Brazil.,Department of Physiology and Pharmacology, Federal University of Santa Maria, Santa Maria, RS, Brazil
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Abdulla A, Ewoldt TMJ, Purmer IM, Muller AE, Gommers D, Endeman H, Koch BCP. A narrative review of predictors for β-lactam antibiotic exposure during empirical treatment in critically ill patients. Expert Opin Drug Metab Toxicol 2021; 17:359-368. [PMID: 33463382 DOI: 10.1080/17425255.2021.1879049] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION : Emerging studies suggest that antibiotic pharmacokinetics (PK) are difficult to predict in critically ill patients. The high intra- and inter-patient PK variability makes it challenging to accurately predict the appropriate dosage required for a given patient. Identifying patients at risk could help clinicians to consider more individualized dosing regimens and perform therapeutic drug monitoring. We provide an overview of relevant predictors associated with target (non-)attainment of β-lactam antibiotics in critically ill patients. AREAS COVERED : This narrative review summarizes patient and clinical characteristics that can help to predict the attainment of target serum concentrations and to provide guidance on antimicrobial dose optimization. Literature was searched using Embase and Medline database, focusing on β-lactam antibiotics in critically ill patients. EXPERT OPINION : Adequate concentration attainment can be anticipated in critically ill patients prior to initiating empiric β-lactam antibiotic therapy based on readily available demographic and clinical factors. Male gender, younger age, and augmented renal clearance were the most significant predictors for target non-attainment and should be considered in further investigations to develop dosing algorithms for optimal β-lactam therapy.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tim M J Ewoldt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ilse M Purmer
- Department of Intensive Care, Haga Hospital, The Hague, The Netherlands
| | - Anouk E Muller
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Medical Microbiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
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13
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Simon P, Petroff D, Busse D, Heyne J, Girrbach F, Dietrich A, Kratzer A, Zeitlinger M, Kloft C, Kees F, Wrigge H, Dorn C. Meropenem Plasma and Interstitial Soft Tissue Concentrations in Obese and Nonobese Patients-A Controlled Clinical Trial. Antibiotics (Basel) 2020; 9:antibiotics9120931. [PMID: 33371322 PMCID: PMC7767385 DOI: 10.3390/antibiotics9120931] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/17/2020] [Accepted: 12/18/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This controlled clinical study aimed to investigate the impact of obesity on plasma and tissue pharmacokinetics of meropenem. METHODS Obese (body mass index (BMI) ≥ 35 kg/m2) and age-/sex-matched nonobese (18.5 kg/m2 ≥ BMI ≤ 30 kg/m2) surgical patients received a short-term infusion of 1000-mg meropenem. Concentrations were determined via high performance liquid chromatography-ultraviolet (HPLC-UV) in the plasma and microdialysate from the interstitial fluid (ISF) of subcutaneous tissue up to eight h after dosing. An analysis was performed in the plasma and ISF by noncompartmental methods. RESULTS The maximum plasma concentrations in 15 obese (BMI 49 ± 11 kg/m2) and 15 nonobese (BMI 24 ± 2 kg/m2) patients were 54.0 vs. 63.9 mg/L (95% CI for difference: -18.3 to -3.5). The volume of distribution was 22.4 vs. 17.6 L, (2.6-9.1), but the clearance was comparable (12.5 vs. 11.1 L/h, -1.4 to 3.1), leading to a longer half-life (1.52 vs. 1.31 h, 0.05-0.37) and fairly similar area under the curve (AUC)8h (78.7 vs. 89.2 mg*h/L, -21.4 to 8.6). In the ISF, the maximum concentrations differed significantly (12.6 vs. 18.6 L, -16.8 to -0.8) but not the AUC8h (28.5 vs. 42.0 mg*h/L, -33.9 to 5.4). Time above the MIC (T > MIC) in the plasma and ISF did not differ significantly for MICs of 0.25-8 mg/L. CONCLUSIONS In morbidly obese patients, meropenem has lower maximum concentrations and higher volumes of distribution. However, due to the slightly longer half-life, obesity has no influence on the T > MIC, so dose adjustments for obesity seem unnecessary.
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Affiliation(s)
- Philipp Simon
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (J.H.); (F.G.); (H.W.)
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (A.D.)
- Correspondence: ; Tel.: +49-341-97-17700
| | - David Petroff
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (A.D.)
- Clinical Trial Centre Leipzig, University of Leipzig, 04107 Leipzig, Germany
| | - David Busse
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (C.K.)
- Graduate Research Training Program PharMetrX, 12169 Berlin, Germany
| | - Jana Heyne
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (J.H.); (F.G.); (H.W.)
| | - Felix Girrbach
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (J.H.); (F.G.); (H.W.)
| | - Arne Dietrich
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (A.D.)
- Department of Surgery, University of Leipzig Medical Centre, 04103 Leipzig, Germany
| | - Alexander Kratzer
- Institute of Pharmacy, University of Regensburg, 93053 Regensburg, Germany; (A.K.); (C.D.)
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169 Berlin, Germany; (D.B.); (C.K.)
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, 93053 Regensburg, Germany;
| | - Hermann Wrigge
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, 04103 Leipzig, Germany; (J.H.); (F.G.); (H.W.)
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, 04103 Leipzig, Germany; (D.P.); (A.D.)
- Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, 06112 Halle, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, 93053 Regensburg, Germany; (A.K.); (C.D.)
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McCoy JA, Elovitz MA, Alby K, Koelper NC, Nissim I, Levine LD. Association of Obesity With Maternal and Cord Blood Penicillin Levels in Women With Group B Streptococcus Colonization. Obstet Gynecol 2020; 136:756-764. [PMID: 32925625 PMCID: PMC11106779 DOI: 10.1097/aog.0000000000004020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare maternal and cord blood penicillin concentrations in women with and without obesity who are receiving intrapartum group B streptococcus (GBS) prophylaxis. METHODS We performed a prospective cohort study of term women receiving intrapartum penicillin prophylaxis for GBS colonization (determined by antenatal rectovaginal culture). The following outcomes were compared between obese (body mass index [BMI] 35 or higher at delivery) and nonobese (BMI less than 30 at delivery) groups: penicillin concentration in maternal blood (after two penicillin doses) and umbilical cord blood, GBS rectovaginal colonization status on admission and after two completed doses, and neonatal GBS colonization (using a postnatal ear swab). Fifty-five women were needed to detect a 0.75 SD difference in cord blood penicillin concentrations. RESULTS Fifty-five women were enrolled and had all specimens collected; 49 had complete data for analysis (obese n=25, nonobese n=24). There was no difference in the median maternal penicillin concentration between groups (obese 4.2 micrograms/mL vs nonobese 4.0 micrograms/mL, P=.58). There was, however, a 60% lower median cord blood penicillin concentration in the obese compared with the nonobese group (2.7 micrograms/mL vs 6.7 micrograms/mL, respectively, P<.01), with no significant difference in time from last penicillin dose to delivery (obese 2.9 hours vs nonobese 1.7 hours, P=.07). The difference in cord blood concentrations remained significant after adjustment for nulliparity, hypertensive disorders, and time from last penicillin dose to delivery. Only 59.6% of women tested positive for GBS by rectovaginal culture on admission (obese 60.9% vs nonobese 58.3%, P=.86). CONCLUSION The median cord blood penicillin concentration was 60% lower in neonates born to women with obesity compared with those born to women without obesity. However, all concentrations exceeded the minimum inhibitory concentration. Maternal penicillin levels were not significantly different between groups. More than 40% of women who previously tested positive for GBS by antenatal culture tested negative for GBS on admission for delivery.
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Affiliation(s)
- Jennifer A McCoy
- Maternal and Child Health Research Center, Department of Obstetrics & Gynecology, and the Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, the Division of Genetics and Metabolism, Children's Hospital of Philadelphia, and the Department of Pediatrics, Biochemistry, and Biophysics, University of Pennsylvania, Philadelphia, Pennsylvania
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15
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Parker SL, Abdul-Aziz MH, Roberts JA. The role of antibiotic pharmacokinetic studies performed post-licensing. Int J Antimicrob Agents 2020; 56:106165. [PMID: 32941948 DOI: 10.1016/j.ijantimicag.2020.106165] [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: 03/31/2020] [Revised: 07/29/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
Post-licensing pharmacometric studies can provide a better understanding of the pharmacokinetic (PK) alterations in special patient populations and may lead to better clinical outcomes. Some patient populations exhibit markedly different pathophysiology to general ward patients or healthy individuals. This may be developmental (paediatric patients), a manifestation of an underlying disease pathology (patients with obesity or haematological malignancies) or due to medical interventions (critically ill patients receiving extracorporeal therapies). This paper outlines the factors that affect the PK of special patient populations and describes some novel methods of antimicrobial administration that may increase antimicrobial concentrations at the site of infection and improve treatment of severe infection.
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Affiliation(s)
- Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
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16
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Measuring Unbound Versus Total Piperacillin Concentrations in Plasma of Critically Ill Patients: Methodological Issues and Relevance. Ther Drug Monit 2020; 41:325-330. [PMID: 30633089 DOI: 10.1097/ftd.0000000000000602] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Piperacillin is considered a moderately protein-bound antibiotic (20%-40%), with albumin being an important binding protein. Although infrequently used in practice, different methods to measure the fraction unbound (fu) are available, but uncertainty remains as to what the most appropriate method is. The main goal of this study was to estimate the impact of the methodology used to measure unbound piperacillin in plasma on the fu of piperacillin; we compared ultrafiltration (UF) at 4°C and 37°C with the reference method, equilibrium dialysis. In addition, we analyzed the impact of other proteins on the fu. METHODS Anonymized left-over Li-heparin plasma samples (n = 41) from 30 critically ill patients who were treated with piperacillin were used for the analyses. RESULTS We found that the piperacillin fu, determined by UF, is on average 8% higher at 37°C (91%) than at 4°C (83%). There were no systematic or proportional differences between UF at 4°C and equilibrium dialysis at 4°C. This emphasizes the importance of the temperature during UF, which should therefore be clearly stated in publications that report on the methodology of UF. No significant impact of the albumin-, IgA-, total protein-, or α1-acid glycoprotein concentration on the fu was found. The fu found in this study was higher than the generally assumed fu value of 60%-80%. A possible explanation lies in the studied population or in the temperature used. Based on our results, routine monitoring of unbound piperacillin in intensive care unit patients is not recommended. CONCLUSIONS Based on the prediction model, we can state that in intensive care patients the fu of piperacillin is 91% (SD 7%), determined with UF at 37°C.
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17
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Brinkmann A, Röhr AC, Köberer A, Fuchs T, Krüger WA, König C, Richter D, Weigand MA, Frey OR. [Adequate anti-infective treatment : Importance of individual dosing and application]. Anaesthesist 2019; 67:461-476. [PMID: 29766208 DOI: 10.1007/s00101-018-0443-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sepsis-induced changes in pharmacokinetic parameters are a well-known problem in intensive care medicine. Dosing of antibiotics in this setting is therefore challenging. Alterations to the substance-specific kinetics of anti-infective substances have an effect on the distribution and excretion processes in the body. Increased clearance and an increased distribution volume (Vd) and particularly compromized organ function with reduced antibiotic elimination are often encountered in patients with sepsis. Renal replacement treatment, which is frequently used in intensive care medicine, represents a substantial intervention in this system. Current international guidelines recommend individualized dosing strategies and adaptation of doses according to measured serum levels and pharmacokinetic/pharmacodynamic (PK/PD) parameters as concepts to optimize anti-infective therapy in the critically ill. Likewise, the recommendation to adjust the administration form of beta-lactam antibiotics to prolonged or continuous infusion can be found increasingly more often in the literature. This article reviews the background of the individual dosing in intensive care patients and their applicability to the clinical routine.
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Affiliation(s)
- A Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland.
| | - A C Röhr
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
| | - A Köberer
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland
| | - T Fuchs
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Schlosshaustr. 100, 89522, Heidenheim, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie und Operative Intensivmedizin, Klinikum Konstanz, Konstanz, Deutschland
| | - C König
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland.,Klinikapotheke, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - D Richter
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - O R Frey
- Apotheke, Klinikum Heidenheim, Heidenheim, Deutschland
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18
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Therapeutic drug monitoring-guided continuous infusion of piperacillin/tazobactam significantly improves pharmacokinetic target attainment in critically ill patients: a retrospective analysis of four years of clinical experience. Infection 2019; 47:1001-1011. [PMID: 31473974 DOI: 10.1007/s15010-019-01352-z] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/22/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Standard dosing and intermittent bolus application (IB) are important risk factors for pharmacokinetic (PK) target non-attainment during empirical treatment with β-lactams in critically ill patients, particularly in those with sepsis and septic shock. We assessed the effect of therapeutic drug monitoring-guided (TDM), continuous infusion (CI) and individual dosing of piperacillin/tazobactam (PIP) on PK-target attainment in critically ill patients. METHODS This is a retrospective, single-center analysis of a database including 484 patients [933 serum concentrations (SC)] with severe infections, sepsis and septic shock who received TDM-guided CI of PIP in the intensive care unit (ICU) of an academic teaching hospital. The PK-target was defined as a PIP SC between 33 and 64 mg/L [fT > 2-4 times the epidemiological cutoff value (ECOFF) of Pseudomonas aeruginosa (PSA)]. RESULTS PK-target attainment with standard dosing (initial dose) was observed in 166 patients (34.3%), whereas only 49 patients (10.1%) demonstrated target non-attainment. The minimum PK-target of ≥ 33 mg/L was overall realized in 89.9% (n = 435/484) of patients after the first PIP dose including 146 patients (30.2%) with potentially harmful SCs ≥ 100 mg/L. Subsequent TDM-guided dose adjustments significantly enhanced PK-target attainment to 280 patients (62.4%) and significantly reduced the fraction of potentially overdosed (≥ 100 mg/L) patients to 4.5% (n = 20/449). Renal replacement therapy (RRT) resulted in a relevant reduction of PIP clearance (CLPIP): no RRT CLPIP 6.8/6.3 L/h (median/IQR) [SCs n = 752, patients n = 405], continuous veno-venous hemodialysis (CVVHD) CLPIP 4.3/2.6 L/h [SCs n = 160, n = 71 patients], intermittent hemodialysis (iHD) CLPIP 2.6/2.3 L/h [SCs n = 21, n = 8 patients]). A body mass index (BMI) of > 40 kg/m2 significantly increased CLPIP 9.6/7.7 L/h [SC n = 43, n = 18 patients] in these patients. Age was significantly associated with supratherapeutic PIP concentrations (p < 0.0005), whereas high CrCL led to non-target attainment (p < 0.0005). Patients with target attainment (33-64 mg/L) within the first 24 h exhibited the lowest hospital mortality rates (13.9% [n = 23/166], p < 0.005). Those with target non-attainment demonstrated higher mortality rates (≤ 32 mg/L; 20.8% [n = 10/49] ≥ 64 mg/L; 29.4% [n = 79/269]). CONCLUSION TDM-guided CI of PIP is safe in critically ill patients and improves PK-target attainment. Exposure to defined PK-targets impacts patient mortality while lower and higher than intended SCs may influence the outcome of critically ill patients. Renal function and renal replacement therapy are main determinants of PK-target attainment. These results are only valid for CI of PIP and not for prolonged or intermittent bolus administration of PIP.
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β-Lactams Dosing in Overweight Critically Ill Patients: Are We Driving in the Dark? Crit Care Med 2019; 45:923-925. [PMID: 28410315 DOI: 10.1097/ccm.0000000000002388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Guilhaumou R, Benaboud S, Bennis Y, Dahyot-Fizelier C, Dailly E, Gandia P, Goutelle S, Lefeuvre S, Mongardon N, Roger C, Scala-Bertola J, Lemaitre F, Garnier M. Optimization of the treatment with beta-lactam antibiotics in critically ill patients-guidelines from the French Society of Pharmacology and Therapeutics (Société Française de Pharmacologie et Thérapeutique-SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation-SFAR). Crit Care 2019; 23:104. [PMID: 30925922 PMCID: PMC6441232 DOI: 10.1186/s13054-019-2378-9] [Citation(s) in RCA: 278] [Impact Index Per Article: 55.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/26/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Beta-lactam antibiotics (βLA) are the most commonly used antibiotics in the intensive care unit (ICU). ICU patients present many pathophysiological features that cause pharmacokinetic (PK) and pharmacodynamic (PD) specificities, leading to the risk of underdosage. The French Society of Pharmacology and Therapeutics (SFPT) and the French Society of Anaesthesia and Intensive Care Medicine (SFAR) have joined forces to provide guidelines on the optimization of beta-lactam treatment in ICU patients. METHODS A consensus committee of 18 experts from the two societies had the mission of producing these guidelines. The entire process was conducted independently of any industry funding. A list of questions formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes) was drawn-up by the experts. Then, two bibliographic experts analysed the literature published since January 2000 using predefined keywords according to PRISMA recommendations. The quality of the data identified from the literature was assessed using the GRADE® methodology. Due to the lack of powerful studies having used mortality as main judgement criteria, it was decided, before drafting the recommendations, to formulate only "optional" recommendations. RESULTS After two rounds of rating and one amendment, a strong agreement was reached by the SFPT-SFAR guideline panel for 21 optional recommendations and a recapitulative algorithm for care covering four areas: (i) pharmacokinetic variability, (ii) PK-PD relationship, (iii) administration modalities, and (iv) therapeutic drug monitoring (TDM). The most important recommendations regarding βLA administration in ICU patients concerned (i) the consideration of the many sources of PK variability in this population; (ii) the definition of free plasma concentration between four and eight times the Minimal Inhibitory Concentration (MIC) of the causative bacteria for 100% of the dosing interval as PK-PD target to maximize bacteriological and clinical responses; (iii) the use of continuous or prolonged administration of βLA in the most severe patients, in case of high MIC bacteria and in case of lower respiratory tract infection to improve clinical cure; and (iv) the use of TDM to improve PK-PD target achievement. CONCLUSIONS The experts strongly suggest the use of personalized dosing, continuous or prolonged infusion and therapeutic drug monitoring when administering βLA in critically ill patients.
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Affiliation(s)
- Romain Guilhaumou
- AP-HM Hôpital de la Timone, Service de Pharmacologie Clinique et Pharmacovigilance, 264 rue Saint Pierre, 13005 Marseille, France
| | - Sihem Benaboud
- AP-HP Hôpital Cochin, Service de Pharmacologie, 27 rue du Faubourg St-Jacques, 75679 Paris Cedex 14, France
| | - Youssef Bennis
- CHU d’Amiens Picardie, Service de Pharmacologie Clinique, UPJV EA7517, Avenue Laennec, 80054 Amiens Cedex 1, France
| | - Claire Dahyot-Fizelier
- CHU de Poitiers, Département d’Anesthésie Réanimation, 2 Rue de la Milétrie, 86021 Poitiers, France
| | - Eric Dailly
- CHU de Nantes, Département de Pharmacologie Clinique, 5 allée de l’île gloriette, 44093 Nantes Cedex 01, France
| | - Peggy Gandia
- CHU de Toulouse, Laboratoire de Pharmacocinétique et Toxicologie Clinique, Institut Fédératif de Biologie, 330, avenue de Grande-Bretagne, 31059 Toulouse cedex 9, France
| | - Sylvain Goutelle
- CHU de Lyon, Service de Pharmacie, Groupement Hospitalier Nord, Hôpital Pierre Garraud, 136 rue du Commandant Charcot, 69322 Lyon cedex 05, France
| | - Sandrine Lefeuvre
- CHR d’Orléans, Laboratoire de Biochimie, 14 Avenue de l’Hôpital, 45067 Orléans, France
| | - Nicolas Mongardon
- AP-HP Hôpital Henri Mondor, Département d’Anesthésie-Réanimation, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Claire Roger
- CHU de Nîmes, Département d’anesthésie, réanimation, douleur et médicine d’urgence, Place du Pr Robert Debré, 30029 Nîmes cedex 9, France
| | - Julien Scala-Bertola
- CHRU de Nancy, Département de pharmacologie clinique et de toxicologie, 29 rue Lionnois, 54000 Nancy, France
| | - Florian Lemaitre
- CHU Pontchaillou, Service de Pharmacologie Clinique et épidémiologique, 2 Rue Henri le Guilloux, 35000 Rennes, France
| | - Marc Garnier
- AP-HP Hôpital Tenon, Département d’Anesthésie et Réanimation, 4 rue de la Chine, 75020 Paris, France
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Pharmacokinetic/Pharmacodynamic Considerations of Beta-Lactam Antibiotics in Adult Critically Ill Patients. Curr Infect Dis Rep 2018; 20:9. [PMID: 29619607 DOI: 10.1007/s11908-018-0613-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE OF REVIEW Beta-lactam antibiotics are commonly prescribed in critically ill patients for a variety of infectious conditions. Our understanding of how critical illness alters beta-lactam pharmacokinetics/pharmacodynamics (PK/PD) is rapidly evolving. RECENT FINDINGS There is a growing body of literature in adult patients demonstrating that physiological alterations occurring in critically ill patients may limit our ability to optimally dose beta-lactam antibiotics to reach these PK/PD targets. These alterations include changes in volume of distribution and renal clearance with multiple, often overlapping causative pathways, including hypoalbuminemia, renal replacement therapy, and extracorporeal membrane oxygenation. Strategies to overcome these PK alterations include extended infusions and therapeutic drug monitoring. Combined data has demonstrated a possible survival benefit associated with extending beta-lactam infusions in critically ill adult patients. This review highlights research on physiological derangements affecting beta-lactam concentrations and strategies to optimize beta-lactam PK/PD in critically ill adults.
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22
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Meng L, Mui E, Holubar MK, Deresinski SC. Comprehensive Guidance for Antibiotic Dosing in Obese Adults. Pharmacotherapy 2017; 37:1415-1431. [DOI: 10.1002/phar.2023] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lina Meng
- Department of Pharmacy; Stanford Health Care; Stanford California
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
| | - Emily Mui
- Department of Pharmacy; Stanford Health Care; Stanford California
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
| | - Marisa K. Holubar
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
- Division of Infectious Diseases and Geographic Medicine; Stanford University School of Medicine; Stanford California
| | - Stan C. Deresinski
- Stanford Antimicrobial Safety and Sustainability Program; Stanford Health Care; Stanford California
- Division of Infectious Diseases and Geographic Medicine; Stanford University School of Medicine; Stanford California
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Repeated Piperacillin-Tazobactam Plasma Concentration Measurements in Severely Obese Versus Nonobese Critically Ill Septic Patients and the Risk of Under- and Overdosing. Crit Care Med 2017; 45:e470-e478. [PMID: 28240688 DOI: 10.1097/ccm.0000000000002287] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Obesity and critical illness modify pharmacokinetics of antibiotics, but piperacillin-tazobactam continuous IV infusion pharmacokinetics has been poorly studied in obese critically ill patients. We aimed to compare pharmacokinetics of piperacillin in severely obese and nonobese patients with severe sepsis or septic shock. We hypothesized that plasma concentration variability would expose the critically ill to both piperacillin under and overdosing. METHODS Prospective comparative study. Consecutive critically ill severely obese (body mass index, > 35 kg/m) and nonobese patients (body mass index, < 30 kg/m) were treated with 16 g/2 g/24 hr continuous piperacillin-tazobactam infusion. Piperacillin plasma concentration was measured every 12 hours over a 7-day period by high-pressure liquid chromatography. Unbound piperacillin plasma concentration and fractional time of plasma concentration spent over 64 mg/L (4-fold the minimal inhibitory concentration for Pseudomonas aeruginosa) were compared between the two groups. We performed 5,000 Monte Carlo simulations for various dosing regimens and minimal inhibitory concentration and calculated the probability to spend 100% of the time over 64 mg/L. RESULTS We enrolled 11 severely obese and 12 nonobese patients and obtained 294 blood samples. We did not observe a statistically significant difference in piperacillin plasma concentrations over time between groups. The fractional time over 64 mg/L was 64% (43-82%) and 93% (85-100%) in obese and nonobese patients, respectively, p = 0.027 with intra- and intergroup variability. Five nonobese and two obese patients experienced potentially toxic piperacillin plasma concentrations. When 64 mg/L was targeted, Monte Carlo simulations showed that 12 g/1.5 g/24 hr was inadequate in both groups and 16 g/2 g/24 hr was adequate only in nonobese patients. CONCLUSION Using a conventional dosing of 16 g/2 g/24 hr continuous infusion, obese patients were more likely than nonobese patients to experience piperacillin underdosing when facing high minimal inhibitory concentration pathogens. The present study suggests that piperacillin drug monitoring might be necessary in the sickest patients who are at the highest risk of unpredictable plasma concentration exposing them to overdose, toxicity, underdosing, and treatment failure.
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Bellmann R. [Personalised pharmacotherapy in intensive care unit patients]. Med Klin Intensivmed Notfmed 2017; 112:289-294. [PMID: 28466289 DOI: 10.1007/s00063-017-0284-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 01/10/2023]
Abstract
Critically ill patients need fast, effective and safe pharmacotherapy. The pharmacokinetics and pharmacodynamics of the administered drugs are influenced by numerous individual conditions. Genetic factors mainly determines drug metabolism. However, therapeutic decisions are not yet guided by genetic analyses. In elderly patients, the volume of distribution can be altered and renal elimination may be delayed. Drug-drug interactions involving current medications can increase the incidence of adverse effects from treatment in the intensive care unit. In early severe sepsis, plasma levels of water-soluble drugs can be decreased because of enhanced volume of distribution and increased renal clearance. Later on, drug elimination can be impaired by deterioration of liver and renal function. Furthermore, the pharmacokinetic effects of continuous renal replacement therapy have to be considered. Plasma levels of critically ill patients show increased variability in comparison with healthy subjects or other patient groups. The therapeutic effect of antibiotics and of many other drugs cannot be assessed immediately. As dosage of these medications cannot be guided by their clinical efficacy, insufficient exposure or overdosage accompanied by toxic side effects may result. Standard dose recommendations that were developed in healthy volunteers or noncritically ill patients must be adapted to individual conditions and requirements of critically ill patients.
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Affiliation(s)
- R Bellmann
- Arbeitsgruppe Klinische Pharmakokinetik, Labor für Inflammationsforschung, Gemeinsame Einrichtung Internistische Notfall- und Intensivmedizin, Department Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
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Population Pharmacokinetics of Piperacillin in Nonobese, Obese, and Morbidly Obese Critically Ill Patients. Antimicrob Agents Chemother 2017; 61:AAC.01276-16. [PMID: 28052849 DOI: 10.1128/aac.01276-16] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 12/24/2016] [Indexed: 01/17/2023] Open
Abstract
The treatment of infections in critically ill obese and morbidly obese patients is challenging because of the combined physiological changes that result from obesity and critical illness. The aim of this study was to describe the population pharmacokinetics of piperacillin in a cohort of critically ill patients, including obese and morbidly obese patients. Critically ill patients who received piperacillin-tazobactam were classified according to their body mass index (BMI) as nonobese, obese, and morbidly obese. Plasma samples were collected, and piperacillin concentrations were determined by a validated chromatographic method. Population pharmacokinetic analysis and Monte Carlo dosing simulations were performed using Pmetrics software. Thirty-seven critically ill patients (including 12 obese patients and 12 morbidly obese patients) were enrolled. The patients' mean ± standard deviation age, weight, and BMI were 50 ± 15 years, 104 ± 35 kg, and 38.0 ± 15.0 kg/m2, respectively. The concentration-time data were best described by a two-compartment linear model. The mean ± SD parameter estimates for the final covariate model were a clearance of 14.0 ± 7.1 liters/h, a volume of distribution of the central compartment of 49.0 ± 19.0 liters, an intercompartmental clearance from the central compartment to the peripheral compartment of 0.9 ± 0.6 liters · h-1, and an intercompartmental clearance from the peripheral compartment to the central compartment of 2.3 ± 2.8 liters · h-1 A higher measured creatinine clearance and shorter-duration infusions were associated with a lower likelihood of achieving therapeutic piperacillin exposures in patients in all BMI categories. Piperacillin pharmacokinetics are altered in the presence of obesity and critical illness. As with nonobese patients, prolonged infusions increase the likelihood of achieving therapeutic concentrations.
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El-Najjar N, Jantsch J, Gessner A. The use of liquid chromatography-tandem mass spectrometry for therapeutic drug monitoring of antibiotics in cancer patients. ACTA ACUST UNITED AC 2017; 55:1246-1261. [DOI: 10.1515/cclm-2016-0700] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 11/28/2016] [Indexed: 12/24/2022]
Abstract
AbstractCancer remains a leading cause of mortality and morbidity worldwide. In addition to organ failure, the most frequent reasons for admission of cancer patients to intensive care units (ICU) are: infections and sepsis. As critically ill, the complexity of the health situation of cancer patients renders the standard antimicrobial regimen more complex and even inadequate which results in increased mortality rates. This is due to pathophysiological changes in the volume of distribution, increased clearance, as well as to organ dysfunction. While in the former cases a decrease in drug efficacy is observed, the hallmark of the latter one is overdosing leading to increased toxicity at the expense of efficacy. Furthermore, an additional risk factor is the potential drug-drug interaction between antibiotics and antineoplastic agents. Therefore, therapeutic drug monitoring (TDM) is a necessity to improve the clinical outcome of antimicrobial therapy in cancer patients. To be applied in routine analysis the method used for TDM should be cheap, fast and highly accurate/sensitive. Furthermore, as ICU patients are treated with a cocktail of antibiotics the method has to cover the simultaneous analysis of antibiotics used as a first/second line of treatment. The aim of the current review is to briefly survey the pitfalls in the current antimicrobial therapy and the central role of TDM in dose adjustment and drug-drug interaction’s evaluation. A major section is dedicated to summarize the currently published analytical methods and to shed light on the difficulties and potential problems that can be encountered during method development.
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Usman M, Frey OR, Hempel G. Population pharmacokinetics of meropenem in elderly patients: dosing simulations based on renal function. Eur J Clin Pharmacol 2016; 73:333-342. [PMID: 27966034 DOI: 10.1007/s00228-016-2172-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 12/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate different dosage regimens of meropenem in elderly patients in relation with renal function using a population pharmacokinetic (popPK) model. METHODS The data of 178 elderly patients treated with meropenem was collected from different sources. A popPK model was developed by using NONMEM® and the influence of different covariates on meropenem CL and V1 was observed. Monte Carlo dosing simulations were performed at steady state to observe the % T > MIC for targets of 40, 60 and 80% of dosage intervals at different levels of creatinine clearance (CLCR). RESULTS The data was described by a two-compartment model and the values of parameter estimates for CL, V1, Q and V2 were 5.27 L/h, 17.2 L, 9.92 L/h and 10.6 L, respectively. The CLCR, body weight and centre had a significant influence on meropenem CL while no direct influence of age was observed. Extended infusions had pharmacokinetic and pharmacodynamic (PK/PD) breakpoint one dilution greater than corresponding short infusion regimens for each target of % T > MIC. CONCLUSION Meropenem CL was significantly lower in the elderly compared to CL reported in younger patients due to the reduced renal function. An extended infusion of 1000 mg q8h can be considered for empirical treatment of infections in elderly patients when CLCR is ≤ 50 mL/min. A continuous infusion of 3000 mg daily dose is preferred if CLCR > 50 mL/min. However, a higher daily dose of meropenem would be required for resistant strains (MIC >8 mg/L) of bacteria if CLCR is >100 mL/min.
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Affiliation(s)
- Muhammad Usman
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.,Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Otto R Frey
- Department of Pharmacy, Hospital of Heidenheim, Heidenheim, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, University of Muenster, Corrensstr. 48, 48149, Muenster, Germany.
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Chung EK, Cheatham SC, Fleming MR, Healy DP, Kays MB. Population Pharmacokinetics and Pharmacodynamics of Meropenem in Nonobese, Obese, and Morbidly Obese Patients. J Clin Pharmacol 2016; 57:356-368. [PMID: 27530916 DOI: 10.1002/jcph.812] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/11/2016] [Indexed: 01/21/2023]
Abstract
The study objective was to evaluate meropenem population pharmacokinetics and pharmacodynamics in nonobese, obese, and morbidly obese patients. Forty adult patients-11 nonobese (body mass index [BMI] < 30 kg/m2 ), 9 obese (30 kg/m2 ≤ BMI < 40 kg/m2 ), and 20 morbidly obese (BMI ≥ 40 kg/m2 )-received meropenem 500 mg every 6 hours (q6h), q8h, or q12h or 1 g q6h or q8h, infused over 0.5 hour. Population pharmacokinetic modeling was performed using NONMEM, and 5000-patient Monte-Carlo simulations were performed to calculate probability of target attainment (PTA) for 5 dosing regimens, infused over 0.5 and 3 hours, using fT>MIC of 40%, 54%, and 100% of the dosing interval. A 2-compartment linear-elimination model best described the serum concentration-time data, and creatinine clearance was significantly associated with systemic clearance. Pharmacokinetic parameters were not significantly different among patient groups. In patients with creatinine clearances ≥50 mL/min, all simulated dosing regimens achieved >90% PTA at 40% fT>MIC in all patient groups at MICs ≤2 mg/L. Only 500 mg q8h, infused over 0.5 hour, did not achieve >90% PTA at 54% fT>MIC in nonobese and morbidly obese patients. At 100% fT>MIC, 1 g q6h and 2 g q8h, infused over 3 hours, reliably achieved >90% PTA in all patient groups. Meropenem pharmacokinetics are comparable among nonobese, obese, and morbidly obese patients. Standard dosing regimens provide adequate pharmacodynamic exposures for susceptible pathogens at 40% and 54% fT>MIC, but prolonged infusions of larger doses are needed for adequate exposures at 100% fT>MIC. Dosage adjustments based solely on body weight are unnecessary.
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Affiliation(s)
- Eun Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, Seoul, South Korea
| | | | - Megan R Fleming
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN, USA
| | - Daniel P Healy
- Division of Pharmacy Practice and Administrative Sciences, James L. Winkle College of Pharmacy, University of Cincinnati Academic Health Center, Cincinnati, OH, USA
| | - Michael B Kays
- Department of Pharmacy Practice, Purdue University College of Pharmacy, Indianapolis and West Lafayette, IN, USA
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Effect of Obesity on the Population Pharmacokinetics of Meropenem in Critically Ill Patients. Antimicrob Agents Chemother 2016; 60:4577-84. [PMID: 27185798 DOI: 10.1128/aac.00531-16] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/07/2016] [Indexed: 02/04/2023] Open
Abstract
Severe pathophysiological changes in critical illness can lead to dramatically altered antimicrobial pharmacokinetics (PK). The additional effect of obesity on PK potentially increases the challenge for effective dosing. The aim of this prospective study was to describe the population PK of meropenem for a cohort of critically ill patients, including obese and morbidly obese patients. Critically ill patients prescribed meropenem were recruited into the following three body mass index (BMI) groups: nonobese (18.5 to 29.9 kg/m(2)), obese (30.0 to 39.9 kg/m(2)), and morbidly obese (≥40 kg/m(2)). Serial plasma samples were taken, and meropenem concentrations were determined using a validated chromatographic method. Population PK analysis and Monte Carlo dosing simulations were undertaken with Pmetrics. Nineteen critically ill patients with different BMI categories were enrolled. The patients' mean ± standard deviation (SD) age, weight, and BMI were 49 ± 15.9 years, 95 ± 22.0 kg, and 33 ± 7.0 kg/m(2), respectively. A two-compartment model described the data adequately. The mean ± SD parameter estimates for the final covariate model were as follows: clearance (CL), 15.5 ± 6.0 liters/h; volume of distribution in the central compartment (V1), 11.7 ± 5.8 liters; intercompartmental clearance from the central compartment to the peripheral compartment, 25.6 ± 35.1 liters h(-1); and intercompartmental clearance from the peripheral compartment to the central compartment, 8.32 ± 12.24 liters h(-1) Higher creatinine clearance (CLCR) was associated with a lower probability of target attainment, with BMI having little effect. Although obesity was found to be associated with an increased V1, dose adjustment based on CLCR appears to be more important than patient BMI.
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30
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Alobaid AS, Hites M, Lipman J, Taccone FS, Roberts JA. Effect of obesity on the pharmacokinetics of antimicrobials in critically ill patients: A structured review. Int J Antimicrob Agents 2016; 47:259-68. [PMID: 26988339 DOI: 10.1016/j.ijantimicag.2016.01.009] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 01/19/2016] [Accepted: 01/22/2016] [Indexed: 02/07/2023]
Abstract
The increased prevalence of obesity presents challenges for clinicians aiming to provide optimised antimicrobial dosing in the intensive care unit. Obesity is likely to exacerbate the alterations to antimicrobial pharmacokinetics when the chronic diseases associated with obesity exist with the acute pathophysiological changes associated with critical illness. The purpose of this paper is to review the potential pharmacokinetic (PK) changes of antimicrobials in obese critically ill patients and the implications for appropriate dosing. We found that hydrophilic antimicrobials (e.g. β-lactams, vancomycin, daptomycin) were more likely to manifest altered pharmacokinetics in critically ill patients who are obese. In particular for β-lactam antibiotics, obesity is associated with a larger volume of distribution (V(d)). In obese critically ill patients, piperacillin is also associated with a lower drug clearance (CL). For doripenem, these PK changes have been associated with reduced achievement of pharmacodynamic (PD) targets when standard drug doses are used. For vancomycin, increases in Vd are associated with increasing total body weight (TBW), meaning that the loading dose should be based on TBW even in obese patients. For daptomycin, an increased Vd is not considered to be clinically relevant. For antifungals, little data exist in obese critically ill patients; during fluconazole therapy, an obese patient had a lower V(d) and higher CL than non-obese comparators. Overall, most studies suggested that standard dosage regimens of most commonly used antimicrobials are sufficient to achieve PD targets. However, it is likely that larger doses would be required for pathogens with higher minimum inhibitory concentrations.
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Affiliation(s)
- Abdulaziz S Alobaid
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Maya Hites
- Department of Infectious Diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jeffrey Lipman
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jason A Roberts
- Burns, Trauma & Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.
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