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Hägglund M, Brink M, Martin US, Bremell D, Svensson CJ. Plasma Trough Concentrations of Beta-Lactam Antibiotics in the Early Phase of Septic Shock. Acta Anaesthesiol Scand 2025; 69:e70050. [PMID: 40318028 PMCID: PMC12047412 DOI: 10.1111/aas.70050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2025] [Revised: 03/30/2025] [Accepted: 04/19/2025] [Indexed: 05/07/2025]
Abstract
INTRODUCTION Septic shock necessitates timely antibiotic therapy, often with broad-spectrum beta-lactam antibiotics (ß-LA). To our knowledge, no previous study has examined antibiotic concentrations repeatedly during the initial phase of treatment. This observational study aimed to assess early-phase plasma concentrations of ß-LA in patients with septic shock. METHOD Prospective observational study of patients with septic shock, according to the SEPSIS-3 criteria, who received cefotaxime, piperacillin/tazobactam, or meropenem in accordance with Swedish practice. Demographic and clinical data were recorded for each patient. Consecutive blood samples were obtained during the first 24 h of treatment, and total antibiotic concentrations were measured using liquid chromatography mass spectrometry. Target concentrations were defined as 100% of the time that free (unbound) antibiotic concentrations remained above the minimal inhibitory concentration (fT > MIC). RESULTS Twenty-two patients were included, 15 (68%) were male and the median age was 65.5 years (IQR 46.3-65.5). In-hospital mortality was 7/22 (32%). Antibiotic exposure exceeding 100% fT > MIC was achieved in 16 (73%) of the patients. Four patients did not receive the recommended additional dose between the first and second doses of antibiotics; two of them still achieved 100% fT > MIC, whereas the other two attained 66% and 33% fT > MIC, respectively. Among the patients who received the additional dose, four did not achieve 100% fT > MIC. No relationship between mortality and fT > MIC was observed. Significant associations with achieving 100% fT > MIC were observed for older age (p = 0.045) and illness severity (SAPS3, p = 0.025). CONCLUSION Our findings demonstrate considerable variability in antibiotic exposure during the initial 24 h of septic shock treatment, highlighting a critical gap in understanding the clinical relevance of sub-optimal serum antibiotic concentrations and their potential impact on patient outcomes. EDITORIAL COMMENT Therapeutic drug monitoring of antimicrobials is increasingly being used in research and clinical practice.
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Affiliation(s)
- Malin Hägglund
- Department of Infectious DiseasesRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Magnus Brink
- Department of Infectious DiseasesRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Ulrika Snygg Martin
- Department of Infectious DiseasesRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Daniel Bremell
- Department of Infectious DiseasesRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Carl Johan Svensson
- Department of Anaesthesiology and Intensive CareRegion Västra Götaland, Sahlgrenska University HospitalGothenburgSweden
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences at the Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
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Eudy J, Chase AM, Sharma D, Sulaiman ZI, Anderson A, Huggett A, Gloe L, Anderson DT. Evaluation of Adjunctive Aminoglycoside Therapy Compared to β-Lactam Monotherapy in Critically Ill Patients with Gram-Negative Bloodstream Infections. Antibiotics (Basel) 2025; 14:497. [PMID: 40426563 PMCID: PMC12108242 DOI: 10.3390/antibiotics14050497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2025] [Revised: 05/01/2025] [Accepted: 05/09/2025] [Indexed: 05/29/2025] Open
Abstract
Background/Objectives: Gram-negative bloodstream infections (GN-BSIs) in the critically ill carry significant mortality, which is exacerbated by delays in appropriate therapy. To improve the time to effective therapy, aminoglycosides are often recommended as empiric adjunctive antimicrobials. However, there is a paucity of clinical data supporting this practice. This study's objective was to evaluate the safety and efficacy of adjunctive aminoglycosides compared to β-lactam monotherapy in patients admitted to the intensive care unit (ICU) with GN-BSI. Methods: This was a retrospective, propensity-matched cohort study of critically ill patients with GN-BSI. The primary outcome was 15-day all-cause mortality. The secondary endpoints evaluated included 30-day mortality, ICU-free survival days, 60-day relapse, 30-day readmission, development of acute kidney injury (AKI), and new resistance. Results: A total of 209 propensity-matched patients were included for analysis: 136 received β-lactam monotherapy and 73 received adjunctive aminoglycoside. The primary outcome of 15-day all-cause mortality was not significantly different between groups (17% vs. 21%; p = 0.644). Additional secondary endpoints of 30-day mortality (22% vs. 25%), ICU-free survival (12.1 vs. 12.2 days), 60-day relapse (3.3% vs. 7.4%), and 30-day readmission (23% vs. 18%) did not yield significant differences. The proportion of AKI was higher in the adjunctive aminoglycoside group but was not found to be significantly different (26.5% vs. 37%). Conclusions: The use of adjunctive aminoglycosides for GN-BSI did not affect clinical outcomes in the critically ill.
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Affiliation(s)
- Joshua Eudy
- Department of Pharmacy, Wellstar MCG Health, Augusta, GA 30912, USA
| | - Aaron M. Chase
- Department of Pharmacy, Wellstar MCG Health, Augusta, GA 30912, USA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA 30602, USA
| | - Divisha Sharma
- Department of Medicine, Division of Infectious Diseases, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA (D.T.A.)
| | - Zoheb Irshad Sulaiman
- Department of Medicine, Division of Infectious Diseases, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA (D.T.A.)
| | - August Anderson
- Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Ashley Huggett
- Department of Medicine, Division of Infectious Diseases, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA (D.T.A.)
| | - Lucy Gloe
- Department of Pharmacy, Wellstar MCG Health, Augusta, GA 30912, USA
| | - Daniel T. Anderson
- Department of Medicine, Division of Infectious Diseases, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA (D.T.A.)
- Department of Pharmacology & Toxicology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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Dähne T, Jaki L, Gosert R, Fuchs J, Krumbholz A, Nägele K, Pletz MW, Khanna N, Leuzinger K, Panning M. Herpes Simplex Virus and Drug Resistance - Comprehensive Update on Resistance Mutations and Implications for Clinical Management: A Narrative Review. Clin Microbiol Infect 2025:S1198-743X(25)00237-X. [PMID: 40349973 DOI: 10.1016/j.cmi.2025.04.046] [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: 12/27/2024] [Revised: 04/04/2025] [Accepted: 04/30/2025] [Indexed: 05/14/2025]
Abstract
BACKGROUND Antiviral drug resistance in herpes simplex virus 1 and 2 (HSV-1 & 2) is a significant clinical challenge, particularly in immunocompromised patients. Drug susceptibility testing (DST) aids clinical management and can be conducted through genotypic (partial genome sequencing) or phenotypic (cell culture) methods. Both have inherent limitations: genotypic DST is limited by outdated datasets lacking information on new helicase-primase inhibitors and corresponding phenotypic data as well as sparse clinical correlations. Phenotypic DST is mainly hampered by a lack of standardization and timely results. OBJECTIVES To compile an up-to-date and comprehensive HSV drug resistance dataset encompassing all reported drug resistance-associated mutations (DRMs), polymorphisms, and viral phenotypes. To aggregate clinical conditions with available DST data. SOURCES A PubMed search identified studies (January 2016-September 2024) on DRMs associated with resistance to aciclovir, penciclovir, brivudine, foscarnet, cidofovir, amenamevir, and pritelivir. Data from a previous HSV resistance dataset (pre-2016) were also included. CONTENT In this review, we summarize novel mutations in the thymidine kinase, polymerase, and helicase-primase gene of HSV conferring resistance to antiviral drugs. Clinical information was available for 513 mutations. In 90% of these (461 cases), viral phenotype and clinical assessment were congruent. However, 10% of cases not responding to antiviral therapy showed phenotypically susceptible virus isolates. We present a framework for clinical and diagnostic management of cases with drug resistant HSV infection. IMPLICATIONS This dataset paves the way to harmonize reporting of DRMs for diagnostic labs and to accelerate genotypic DST interpretation through aggregated data. Ongoing large-scale data collection of genotypic, phenotypic, and clinical data is crucial for evidence-based management of HSV antiviral resistance and clinical guidelines.
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Affiliation(s)
- Theo Dähne
- Institute of Virology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Consulting Laboratory for HSV and VZV, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lena Jaki
- Institute of Virology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rainer Gosert
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Jonas Fuchs
- Institute of Virology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andi Krumbholz
- Institute for Infection Medicine, Christian-Albrechts-Universität zu Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany; Labor Dr. Krause und Kollegen Medizinisches Versorgungszentrum GmbH, Kiel, Germany
| | - Klaudia Nägele
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control and Center for Sepsis Care and Control, Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Nina Khanna
- Division of Infectious Diseases, University and University Hospital Basel, Basel, Switzerland
| | - Karoline Leuzinger
- Clinical Virology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Marcus Panning
- Institute of Virology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; German Consulting Laboratory for HSV and VZV, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Truong AQ, Smeets TJL, Terrier J, Li L, Dao XC, Strojil J, Preijers T, Koch BCP, Huttner A, Sassen SDT. Inadequate imipenem dosing in patients with decreased kidney function: A clinical pharmacokinetic study. Clin Microbiol Infect 2025:S1198-743X(25)00233-2. [PMID: 40349972 DOI: 10.1016/j.cmi.2025.05.005] [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: 02/09/2025] [Revised: 04/24/2025] [Accepted: 05/01/2025] [Indexed: 05/14/2025]
Abstract
OBJECTIVES A number of population pharmacokinetic (popPK) models of imipenem in critically ill patients are available for dosing optimisation, but they represent only a narrow range of kidney functions. This study evaluates the target attainment of on-label regimens through popPK modelling and simulation in patients across different kidney functions. METHODS A popPK model was built based on two datasets from Switzerland (model development population, 151 patients, 322 concentrations) and externally validated on two datasets from the Czech Republic (19 patients, 111 concentrations) and Vietnam (43 patients, 85 concentrations). Monte Carlo simulations were performed to evaluate the probability of target attainment (PTA) from a minimum inhibitory concentration (MIC) of 0.125 to 32 mg/L. We estimated the cumulative fraction of response (CFR) against Pseudomonas aeruginosa (the epidemiological cut-off value was 4 mg/L) across a broad range of Cockcroft-Gault creatinine clearance values (CLCRCG 15-130 mL/min). Targets of 40% and 100%ƒT>MIC (percentage of dosing interval estimated free concentrations above MIC) were investigated. RESULTS Decreased kidney function (eGFRCKD-EPI <90mL/min) was observed in 70/151 patients (46.4%) within the model development population, and in 11/19 (57.9%) and 24/43 (55.8%) patients in the Czech Republic and Vietnam, respectively. CLCRCG significantly influenced the imipenem clearance described by a two-compartment model. For PTA, all regimens achieved 40% ƒT>MIC2mg/L. With a 100%ƒT>MIC target, 500 mg q6h (CLCRCG 30-60 mL/min) could only cover a MIC of up to 1 mg/L, irrespective of infusion time. For CFR, no dosing regimen could cover susceptible P. aeruginosa for 100%ƒT>MIC. CONCLUSIONS The highest on-label imipenem dosing regimens failed to attain 100% ƒT>MIC4mg/L in patients with decreased kidney function. Higher dosing may be necessary to cover MIC of 4mg/L. Future trials should explore their efficacy, toxicity, and the utility of model-informed precision dosing in this population.
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Affiliation(s)
- Anh Quan Truong
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands; National Drug Information and Adverse Drug Reaction Monitoring Centre, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Tim J L Smeets
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Jean Terrier
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland; Clinical Pharmacology and Toxicology Service, Anesthesiology Pharmacology and Intensive Care Department, Geneva University Hospitals, Geneva, Switzerland
| | - Letao Li
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Xuan Co Dao
- Intensive Care Unit, Bach Mai Hospital, Hanoi, Vietnam
| | - Jan Strojil
- Department of Pharmacology, Palacky University, Czech Republic
| | - Tim Preijers
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands
| | - Angela Huttner
- Division of Infectious Diseases, Geneva University Hospitals, Faculty of Medicine, Geneva, Switzerland
| | - Sebastiaan D T Sassen
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands; Rotterdam Clinical Pharmacometrics Group, Rotterdam, The Netherlands.
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Farinella A, Salvagno M, Minini A, Attanasio L, Cunha A, Menozzi M, Saravia A, Amado F, Gorham J, Hites M, Taccone FS, Gouvêa Bogossian E. Beta-Lactam Antibiotic Concentrations and the Acquisition of Multi-Drug Resistant Bacteria in Critically Ill Patients. Life (Basel) 2025; 15:739. [PMID: 40430167 PMCID: PMC12113430 DOI: 10.3390/life15050739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2025] [Revised: 04/28/2025] [Accepted: 04/29/2025] [Indexed: 05/29/2025] Open
Abstract
Antimicrobial resistance (AMR) is a worldwide healthcare emergency. Whether insufficient beta-lactam antibiotic concentrations can be associated with AMR emergence remains controversial. This is a retrospective single-center cohort study including patients admitted to the intensive care unit of a tertiary university hospital from 2009 to 2014, who required a broad-spectrum beta-lactam antibiotic and had at least one therapeutic drug monitoring (TDM). Patients were categorized as having inadequate drug levels if the trough concentration (Cmin) fell below the clinical breakpoint for Pseudomonas aeruginosa. AMR was defined according to breakpoints recommended by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) using the disk diffusion method. A total of 444 patients (male sex, n = 313, 71%; female sex, n = 131, 29%; mean age 58 ± 15 years) were enrolled in the study. Patients received piperacillin/tazobactam (n = 168), ceftazidime/cefepime (n = 58) or meropenem (n = 218); among them, 65 (15%) had insufficient drug levels. Nine of these 65 (13.8%) patients with insufficient antibiotic levels acquired at least one pathogen with AMR within 15 days of TDM, when compared to 84/379 (22%) in the other group (OR 0.56 [95%CI 0.27-1.19]; p = 0.13). In a multivariable competing-risk analysis including male gender, APACHE score on admission, previous colonization by other MDR bacteria, urinary catheter, central venous catheter, mechanical ventilation, previous hospitalization and previous surgery, insufficient antibiotic levels were not associated with AMR acquisition (sHR 0.84 [95% CI 0.42-1.68]). Similar results were found when a higher threshold was used to define insufficient drug levels (Cmin < 4 times the clinical breakpoint). In conclusion, insufficient beta-lactam levels were not independently associated with AMR acquisition. Future prospective studies are needed to evaluate better the relationship between low drug levels and antibiotic resistance acquisition.
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Affiliation(s)
- Anita Farinella
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
- Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione—IRCCS ISMETT, 90127 Palermo, Italy
| | - Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Andrea Minini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Laila Attanasio
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Ana Cunha
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Marco Menozzi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Andres Saravia
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Filipe Amado
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Julie Gorham
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Maya Hites
- Clinic of Infectious Diseases, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lenik, 808, 1070 Brussels, Belgium;
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; (A.F.); (M.S.); (A.M.); (L.A.); (A.C.); (M.M.); (A.S.); (F.A.); (J.G.); (F.S.T.)
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Amador JS, Vega Á, Araos P, Quiñones LA, Amador CA. A Successful Experience of Individualized Vancomycin Dosing in Critically Ill Patients by Using a Loading Dose and Maintenance Dose. Pharmaceuticals (Basel) 2025; 18:677. [PMID: 40430496 PMCID: PMC12114607 DOI: 10.3390/ph18050677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2025] [Revised: 04/12/2025] [Accepted: 04/29/2025] [Indexed: 05/29/2025] Open
Abstract
Background/Objective: Vancomycin, a hydrophilic glycopeptide antibiotic with bactericidal activity against Gram-positive microorganisms, is one of the most commonly used antibiotics un the intensive care unit (ICU). Different efforts have been made to achieve a therapeutically effective plasma concentration of vancomycin by using loading and subsequent maintenance doses on an individual basis, but this remains subject to debate. Our objective was to individualize a dosage regimen in a Chilean ICU to optimize the pharmacological treatment of vancomycin by using a population pharmacokinetic model. Methods: A quantitative descriptive study was carried out in 51 patients at the adult ICU, San Borja Arriarán Clinical Hospital in Santiago, Chile. The dose of vancomycin was calculated by using a population pharmacokinetic software, the Antibiotic Kinetics®, and was subsequently validated with plasma trough levels of the drug through a patient sample. Results: The most commonly prescribed loading dose was 1500 mg and the most commonly used maintenance dose was 1000 mg, three times a day. The measured blood plasma concentrations of each patient (16.98 ± 5.423 μg/mL) were compared with the concentrations calculated through the population pharmacokinetic model (14.33 ± 4.630 μg/mL, p < 0.05). In addition, a correlation was found between the software-calculated trough concentration versus the measured trough concentration for vancomycin, with a positive correlation between both variables established (R2 = 0.65; p < 0.0001). No renal side effects were observed in the treated patient group. Conclusions: In the present study, a vancomycin dosing model for critically ill patients, based on a population pharmacokinetic model, was successfully implemented for routine clinical practice.
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Affiliation(s)
- Jorge S. Amador
- Intensive Care Unit, San Borja Arriarán Clinical Hospital, Santiago 8360160, Chile;
- School of Chemistry and Pharmacy, Faculty of Medicine, Universidad Andrés Bello, Santiago 8320000, Chile
| | - Álvaro Vega
- CleanDrugs®, Hospitales y Atención Sanitaria, Concepción 4030000, Chile;
| | - Patricio Araos
- Hypertension and Kidney Immunology Laboratory, Institute of Biomedical Science, Universidad Autónoma de Chile, Santiago 8910060, Chile;
| | - Luis A. Quiñones
- Laboratory of Chemical Carcinogenesis and Pharmacogenetics, Department of Basic-Clinical Oncology, Faculty of Medicine, Universidad de Chile, Santiago 8500000, Chile;
- Department of Technology and Pharmaceutical Sciences, Faculty of Chemical and Pharmaceutical Sciences, University of Chile, Santiago 8380000, Chile
- Latin American Network for Implementation and Validation of Clinical Pharmacogenomics Guidelines (RELIVAF), Santiago 8500000, Chile
| | - Cristián A. Amador
- Faculty of Medicine and Science, Universidad San Sebastián, Santiago 7510157, Chile
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Khan AB, Abdul-Aziz MH, Hindle L, Lipman J, Simelela F, Omar S. Continuous versus intermittent bolus dosing of beta-lactam antibiotics in a South African multi-disciplinary intensive care unit: A randomized controlled trial. J Infect 2025; 90:106487. [PMID: 40239817 DOI: 10.1016/j.jinf.2025.106487] [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: 01/20/2025] [Revised: 03/30/2025] [Accepted: 04/09/2025] [Indexed: 04/18/2025]
Abstract
BACKGROUND Beta-lactams exhibit time-dependent bactericidal effects with continuous infusion (CI) suggested to provide superior antibiotic concentrations compared to intermittent bolus (IB). OBJECTIVE To determine whether beta-lactam CI improves day 14 clinical cure compared to IB in a South African, multi-disciplinary intensive care unit (ICU). METHODS Adult patients with sepsis receiving amoxicillin-clavulanate, piperacillin-tazobactam, imipenem-cilastatin and meropenem were randomized to 24-hour CI or IB. On screening, patients who received study antibiotics for more than 24 h, pregnant patients or patients on renal replacement therapy were excluded. The primary outcome, clinical cure, was defined as completion of antibiotics by day 14 without recommencement within 48 h. Secondary outcomes included ICU length of stay (LOS), ICU, day 28 and day 90 mortality. RESULTS We enrolled 122 patients. The groups were balanced for baseline age, weight, sex, severity of illness, organ support, HIV status, diagnostic category and site of infection. Median antibiotic duration, CI group, 7 days (IQR 5-8.5) vs. IB group, 6 days (IQR 4-8), p=0.191, and median ICU LOS, CI, 9.5 days (IQR 6-15.5) vs. IB, 9 days (IQR 5-16), p= 0.575, were similar. Clinical cure in the CI group was 81% (52/64) vs. 74.1% (43/58) in the IB group), p=0.345. Day 90 relative risk of death was 0,57, 95% Confidence Interval 0.32 - 1.01) for the CI group compared to IB. CONCLUSION Among critically ill patients meeting the sepsis-3 definition, this study could not demonstrate the superiority of continuous infusion of beta-lactam antibiotics compared to intermittent bolus in achieving a clinical cure.
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Affiliation(s)
- Ayesha Bibi Khan
- Division of Critical Care, University of Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
| | - Mohd Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Department of Clinical Pharmacy, Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam, Malaysia.
| | - Lucy Hindle
- Division of Critical Care, University of Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology, Brisbane, Queensland, Australia; Division of Anesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
| | - Fetolang Simelela
- Division of Critical Care, University of Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
| | - Shahed Omar
- Division of Critical Care, University of Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.
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Domes C, Graul L, Frosch T, Popp J, Hagel S, Pletz MW, Frosch T. Impact of clinical preparation steps and use of sex-specific reference for accurate antibiotic monitoring in body fluids. COMMUNICATIONS MEDICINE 2025; 5:120. [PMID: 40240478 PMCID: PMC12003900 DOI: 10.1038/s43856-025-00823-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 03/24/2025] [Indexed: 04/18/2025] Open
Abstract
BACKGROUND Effective antibiotic therapy in critically ill patients requires precise dosing tailored to individual conditions. However, physiological changes in these patients can complicate drug exposure prediction, leading to treatment failure or toxicity. Therapeutic drug monitoring (TDM) is crucial in optimizing antibiotic therapy, with Raman spectroscopy emerging as a promising method due to its speed and sensitivity. METHODS The utility of resonance Raman spectroscopy in analyzing clinical urine samples was investigated, specifically focusing on piperacillin concentrations. Samples subjected to various preparation techniques, including freezing, centrifugation, and filtration, were analyzed using deep UV resonance Raman spectroscopy. Data analysis involved preprocessing and chemometric modeling to assess concentration changes and the influence of sample matrix. RESULTS Sample preparation steps induce concentration changes in piperacillin, with freezing having the highest impact. Chemometric modeling reveals that freezing, filtration, and centrifugation, especially when combined, reduce drug concentration. Furthermore, the choice of urine reference for quantification impacts results, with sex-specific urine pools showing better accuracy compared to mixed pools. CONCLUSIONS Resonance Raman spectroscopy effectively quantifies piperacillin concentrations in urine. Freezing, centrifugation, and filtration during sample preparation influence drug concentration. Using sex-specific urine pools as references yields more accurate quantification results. These findings underscore the importance of considering sample processing effects and reference selection in TDM studies, offering insights for optimizing antibiotic dosing in critically ill patients. Further validation on a larger scale is warranted to confirm these observations.
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Affiliation(s)
- Christian Domes
- Biophotonics and Biomedical Engineering Group, Technical University Darmstadt, Merckstraße 25, 64283, Darmstadt, Germany
- Leibniz Institute of Photonic Technology, 07745, Jena, Germany
| | - Lisa Graul
- Leibniz Institute of Photonic Technology, 07745, Jena, Germany
| | - Timea Frosch
- Leibniz Institute of Photonic Technology, 07745, Jena, Germany
| | - Juergen Popp
- Leibniz Institute of Photonic Technology, 07745, Jena, Germany
| | - Stefan Hagel
- Institute of Infectious Diseases and Infection Control, University Hospital, 07747, Jena, Germany
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, University Hospital, 07747, Jena, Germany
| | - Torsten Frosch
- Biophotonics and Biomedical Engineering Group, Technical University Darmstadt, Merckstraße 25, 64283, Darmstadt, Germany.
- Leibniz Institute of Photonic Technology, 07745, Jena, Germany.
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9
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Reeder JA, Creech CB, Nation RL, Gu K, Nalbant D, Wu N, Jimenez‐Truque N, Fissell W, Rolsma SL, Fishbane N, Kirkpatrick CMJ, Patel PC, Watanabe A, Landersdorfer CB, Winokur P, An G. Utilizing an Opportunistic Clinical Study and Population-Based Pharmacokinetic Models to Identify Rational Empiric Dosing Regimens for Piperacillin-Tazobactam in Critically Ill Patients. J Clin Pharmacol 2025; 65:452-465. [PMID: 39628093 PMCID: PMC11938006 DOI: 10.1002/jcph.6161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2024] [Accepted: 10/25/2024] [Indexed: 03/27/2025]
Abstract
Determining an effective dosing regimen for piperacillin-tazobactam in critically ill patients is challenging due to substantial pharmacokinetic variability caused by complex pathophysiological changes. To address this need, a prospective clinical study was conducted, which enrolled 112 critically ill patients and employed an opportunistic sampling strategy. Population modeling and simulation were performed to characterize the pharmacokinetics (PK) and probability of target attainment (PTA) of piperacillin-tazobactam under various dosing regimens. Both piperacillin and tazobactam final models were one-compartment models with zero-order input and first-order elimination. Significant covariates included lean body weight for piperacillin and creatinine clearance along with continuous renal replacement therapy (CRRT) for both drugs. Monte Carlo simulations demonstrated that continuous infusion can achieve higher PTA than intermittent and extended infusions. When considering the minimum inhibitory concentration (MIC) of 16 mg/L for Pseudomonas aeruginosa (a frequently encountered bacterial pathogen among critically ill patients) and a PK/PD target of 100% fT >MIC, continuous infusion of 6 g/day is recommended for critically ill patients with a CLcr <60 mL/min, 9 g/day for patients with CLcr in the range of 60 to 129 mL/min, and 12 g/day for patients with a CLcr ≥130 mL/min. In addition, extended infusion represents a good alternative, especially the 3 g q6h or 4 g q6h regimens which can achieve the designated European Committee on Antimicrobial Susceptibility Testing (EUCAST) non-species-related PK/PD breakpoint of 8 mg/L. Our study provided valuable insight into PTA outcomes, which, together with individual renal function of future patients and institution-specific piperacillin susceptibility patterns, may assist physicians when making dosing decisions.
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Affiliation(s)
- Joshua A. Reeder
- Department of Pharmaceutical Sciences and Experimental TherapeuticsCollege of PharmacyUniversity of IowaIowa CityIAUSA
| | - C. Buddy Creech
- Division of Pediatric Infectious DiseasesDepartment of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - Roger L. Nation
- Monash Institute of Pharmaceutical SciencesMonash UniversityParkvilleVictoriaAustralia
| | - Kenan Gu
- Division of Microbiology and Infectious DiseasesNational Institute of Allergy and Infectious DiseasesBethesdaMDUSA
| | - Demet Nalbant
- Department of Pharmaceutical Sciences and Experimental TherapeuticsCollege of PharmacyUniversity of IowaIowa CityIAUSA
| | - Nan Wu
- Department of Pharmaceutical Sciences and Experimental TherapeuticsCollege of PharmacyUniversity of IowaIowa CityIAUSA
| | - Natalia Jimenez‐Truque
- Division of Pediatric Infectious DiseasesDepartment of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | - William Fissell
- Division of Nephrology and HypertensionVanderbilt University Medical CenterNashvilleTNUSA
| | - Stephanie L. Rolsma
- Division of Pediatric Infectious DiseasesDepartment of PediatricsVanderbilt University Medical CenterNashvilleTNUSA
| | | | | | - Pratish C. Patel
- Department of Pharmaceutical ServicesVanderbilt University Medical CenterNashvilleTNUSA
| | | | | | - Patricia Winokur
- Department of Infectious DiseasesCarver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Guohua An
- Department of Pharmaceutical Sciences and Experimental TherapeuticsCollege of PharmacyUniversity of IowaIowa CityIAUSA
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10
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Paiboonvong T, Montakantikul P, Panjasawatwong N, Singkham N, Punyawudho B. Population Pharmacokinetics and Pharmacodynamics of Sitafloxacin in Plasma and Alveolar Epithelial Lining Fluid of Critically Ill Thai Patients With Pneumonia. Pharmacol Res Perspect 2025; 13:e70081. [PMID: 40122675 PMCID: PMC11930543 DOI: 10.1002/prp2.70081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2024] [Revised: 01/03/2025] [Accepted: 02/25/2025] [Indexed: 03/25/2025] Open
Abstract
Sitafloxacin is one of the oral respiratory quinolones for the treatment of community-acquired pneumonia. The pharmacokinetic (PK) changes of sitafloxacin in critical illness have been previously reported. However, sitafloxacin exposure and target attainment have never been confirmed in this population. To develop a population pharmacokinetic (PK) model of sitafloxacin, plasma and epithelial lining fluid (ELF) concentrations were obtained after sitafloxacin administration as a 200-mg single dose under fasting condition in 12 subjects. A population pharmacokinetic analysis was performed using a nonlinear mixed-effects modeling approach. The probability of target attainment (PTA) and cumulative fraction of response (CFR) against the MIC distribution of S. pneumoniae isolated from Thai patients was estimated by Monte Carlo simulations. The pharmacokinetics of sitafloxacin in plasma was best described by a one-compartment model linking to the ELF compartment. The partition coefficient which relates drug exposure in ELF to drug exposure in plasma was estimated to be 0.77. Age was a significant covariate that impacted the relative bioavailability. Results from Monte Carlo simulations showed that the maximum approved dose of sitafloxacin 100 mg q 12 h provided > 90% PTA and CFR in both plasma and ELF. The current maximal dosing of sitafloxacin provided adequate exposure in plasma and ELF for the treatment of critically ill Thai patients with pneumonia.
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Affiliation(s)
- Taniya Paiboonvong
- Department of Pharmacy PracticeCollege of Pharmacy, Rangsit UniversityPathum ThaniThailand
| | | | - Navarat Panjasawatwong
- Department of Pharmaceutical CareFaculty of Pharmacy, Payap UniversityChiang MaiThailand
| | - Noppaket Singkham
- Division of Clinical Pharmacy, Department of Pharmaceutical CareSchool of Pharmaceutical Sciences, University of PhayaoPhayaoThailand
| | - Baralee Punyawudho
- Department of Pharmaceutical CareFaculty of Pharmacy, Chiang Mai UniversityChiang MaiThailand
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11
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La Via L, Marino A, Cuttone G, Nunnari G, Deana C, Tesauro M, Voza A, Planinsic R, Longhitano Y, Zanza C. Critical Care Pharmacology of Antiretroviral Therapy in Adults. Eur J Drug Metab Pharmacokinet 2025; 50:105-118. [PMID: 39937350 PMCID: PMC11882694 DOI: 10.1007/s13318-025-00934-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2025] [Indexed: 02/13/2025]
Abstract
The clinical pharmacology of antiretroviral therapy (ART) in critical care presents unique challenges due to the complex interplay between HIV infection, critical illness, and drug management. This comprehensive review examines the pharmacokinetic and pharmacodynamic considerations of antiretroviral drugs in critically ill patients, where altered absorption, distribution, metabolism, and excretion significantly impact drug effectiveness and safety. Critical illness can substantially modify drug pharmacokinetics through various mechanisms, including impaired gastrointestinal motility, fluid shifts, hypoalbuminemia, hepatic dysfunction, and altered renal function. These changes, combined with potential drug-drug interactions in the polypharmacy environment of intensive care units, necessitate careful consideration of dosing strategies and monitoring approaches. The review addresses specific challenges in various critical care scenarios, including management of ART in patients with organ dysfunction, during renal replacement therapy, and in special populations such as those with sepsis or acute respiratory distress syndrome. It also explores the role of therapeutic drug monitoring in optimizing antiretroviral therapy and managing drug toxicities in critical care settings. Emerging areas of research, including long-acting formulations, nanotechnology-based drug delivery systems, and personalized medicine approaches, are discussed as potential future directions for improving ART management in critical care. The review emphasizes the importance of a multidisciplinary approach involving critical care physicians, infectious disease specialists, and clinical pharmacists to optimize outcomes in this complex patient population. This review provides clinicians with practical guidance for managing ART in critically ill patients while highlighting areas requiring further research to enhance our understanding and improve patient care in this challenging setting.
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Affiliation(s)
- Luigi La Via
- Department of Anaesthesia and Intensive Care, University Hospital Policlinico ❝G. Rodolico-San Marco❞, 95123, Catania, Italy
| | - Andrea Marino
- Department of Clinical and Experimental Medicine, Infectious Diseases Unit, ARNAS Garibaldi, University of Catania, 95123, Catania, Italy
| | - Giuseppe Cuttone
- U.O.S.D. Trauma Center, Azienda Ospedaliera 'Ospedali Riuniti Villa Sofia-Cervello', Palermo, Italy
| | - Giuseppe Nunnari
- Department of Clinical and Experimental Medicine, Infectious Diseases Unit, ARNAS Garibaldi, University of Catania, 95123, Catania, Italy
| | - Cristian Deana
- Department of Anesthesia and Critical Care, Health Integrated Agency of Central Friuli, Udine, Italy
| | - Manfredi Tesauro
- Department of Systems Medicine, University of Rome ❝Tor Vergata❞, 00133, Rome, Italy
- Geriatric Medicine Residency Program, University of Rome ❝Tor Vergata❞, 00133, Rome, Italy
| | - Antonio Voza
- Department of Emergency Medicine-Emergency Medicine Residency Program, Humanitas University-Research Hospital, 20089, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072, Milan, Italy
| | - Raymond Planinsic
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Christian Zanza
- Geriatric Medicine Residency Program, University of Rome ❝Tor Vergata❞, 00133, Rome, Italy.
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12
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Gatechan T, Nakaranurack C, Plongla R, Chuenjit T, Gross AE. The impact of pharmacist-led education and prospective audit and feedback on antibiotic dose optimization within medical intensive care units in Thailand: a retrospective study. J Pharm Policy Pract 2025; 18:2467456. [PMID: 40034877 PMCID: PMC11873917 DOI: 10.1080/20523211.2025.2467456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Accepted: 02/10/2025] [Indexed: 03/05/2025] Open
Abstract
Background Critical illness can affect antimicrobial pharmacokinetics and pharmacodynamics. Antimicrobial stewardship programs promote appropriate antimicrobial usage. This study aimed to compare the appropriateness of antibiotic dosing, therapeutic drug monitoring, and ICU mortality before and after antimicrobial stewardship program implementation in medical intensive care units. Methods This retrospective study was conducted at King Chulalongkorn Memorial Hospital, Thailand. Adults admitted to medical intensive care units from August 1, 2019, to July 31, 2021, who received selected antibiotics in the antimicrobial stewardship program were included. During the intervention period, general education as well as prospective audit with intervention and feedback were implemented by infectious disease pharmacist and clinical pharmacists. The appropriateness of dosing, therapeutic drug monitoring, and ICU mortality were compared before and after antimicrobial stewardship program implementation. Results There were 269 patients (455 prescriptions) and 376 patients (604 prescriptions) in the pre- and post-antimicrobial stewardship program implementation groups, respectively. Meropenem was the commonly prescribed antibiotic in both groups. Overall, the appropriateness of dosing and therapeutic drug monitoring improved after antimicrobial stewardship program implementation (36% to 63.58%, p < 0.001). Infectious disease and clinical pharmacists provided 40 interventions with an 87.5% acceptance rate. The most common recommendation was maintenance dose adjustment (79.17% acceptance rate). ICU mortality (29.37% to 18.62%, p = 0.001) and length of hospital stay in the ICU (7 days to 5 days, p = 0.005) were lower in the post-antimicrobial stewardship program implementation group. Conclusions Pharmacist-led education and prospective audit and feedback on antibiotic dose optimization can improve appropriate antibiotic dosing and therapeutic drug monitoring with a high acceptance rate. We suggest implementing this strategy in other intensive care units such as surgical intensive care units. We still found some nonadherence to our dosing guidelines; additional strategies to optimize dosing should be evaluated.
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Affiliation(s)
- Tipanong Gatechan
- Clinical Pharmacy Unit, Department of Pharmacy, Sunprasitthiprasong Hospital, Ubon Ratchatani, Thailand
| | - Chotirat Nakaranurack
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Rongpong Plongla
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Antimicrobial Resistance and Stewardship, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanawan Chuenjit
- Department of Clinical Pharmacy Unit, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Alan Edward Gross
- Department of Pharmacy Practice, Retzky College of Pharmacy, University of Illinois Chicago, Chicago, IL, USA
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13
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Michel J, Monti F, Lamoureux F, Diagouraga D, Etienne M, Quillard M, Molkhou C, Tamion F, Dahyot S, Petersen T, Pereira T, Pestel-Caron M, Grosjean J, Duflot T. Unraveling Ceftriaxone Dosing: Free Drug Prediction, Threshold Optimization, and Model Validation. AAPS J 2025; 27:50. [PMID: 40011393 DOI: 10.1208/s12248-025-01041-w] [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: 11/18/2024] [Accepted: 02/13/2025] [Indexed: 02/28/2025] Open
Abstract
Ceftriaxone is pivotal in treating severe infections; however, predicting unbound plasma ceftriaxone (CEFu) from total ceftriaxone (CEFtot) remains challenging. This study aimed to (1) predict CEFu from CEFtot, (2) determine optimal target for CEFtot trough concentration in plasma, (3) perform an external validation of published models, and (4) to ascertain whether the CEF dosing regimen was sufficient to achieve the therapeutic objectives. CEFu predictions based on CEFtot were evaluated using previously published models. Optimal CEFtot targets for an MIC of 1mg/L were calculated to achieve CEFu concentrations above MIC and 4xMIC 100% of the time. External validation was conducted assessing serum albumin, CEFtot and CEFu and comparing predicted CEFu across models. Retrospective data, comprising 408 CEFtot from 222 patients, were analyzed to assess the probability of target attainment (PTA) based on model predicted CEFu. CEFu predictions based on CEFtot were evaluated using previously published models. Optimal CEFtot targets for an MIC of 1mg/L were calculated to achieve CEFu concentrations above MIC and 4xMIC 100% of the time. External validation was conducted assessing serum albumin, CEFtot and CEFu and comparing predicted CEFu across models. Retrospective data, comprising 408 CEFtot from 222 patients, were analyzed to assess the probability of target attainment (PTA) based on model predicted CEFu. Optimal CEFtot trough concentration targets ranged from 2.0 mg/L to 16.9 mg/L (1xMIC) and from 7.9 mg/L to 56.2 mg/L (4xMIC) across models. Some models accurately predicted CEFu obtained from prospective external validation. In the retrospective cohort, PTA ranged from 94.4% to 98.7% for 1xMIC and from 66.9% to 97.3% for 4xMIC. Modeling or direct quantification of CEFu may improve patient outcomes, but achieving this requires standardized analytical approaches and further research to assess the ability of published models to accurately predict CEFu.
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Affiliation(s)
- Johnny Michel
- Emergency Department, CHU Rouen, F-76000, Rouen, France
| | - Francesco Monti
- Department of Digital Health, CHU Rouen, F-76000, Rouen, France
| | | | | | - Manuel Etienne
- Department of Infectious Diseases, Univ Rouen Normandie, Univ Caen Normandie, INSERM, Normandie Univ, DYNAMICURE UMR 1311, CHU Rouen, F-76000, Rouen, France
| | - Muriel Quillard
- Department of Biochemistry, CHU Rouen, F-76000, Rouen, France
| | - Camille Molkhou
- Department of Medical Intensive Care Unit, CHU Rouen, F-76000, Rouen, France
| | - Fabienne Tamion
- Department of Medical Intensive Care Unit, CHU Rouen, F-76000, Rouen, France
| | - Sandrine Dahyot
- Department of Bacteriology, Univ Rouen Normandie, Univ Caen Normandie, INSERM, Normandie Univ, DYNAMICURE UMR 1311, CHU Rouen, F-76000, Rouen, France
| | - Tania Petersen
- Department of Pharmacology, CHU Rouen, F-76000, Rouen, France
- Department of Bacteriology, AP-HP Hôpital Universitaire Pitié Salpêtrière, Paris, France
| | - Tony Pereira
- Department of Pharmacology, CHU Rouen, F-76000, Rouen, France
| | - Martine Pestel-Caron
- Department of Bacteriology, Univ Rouen Normandie, Univ Caen Normandie, INSERM, Normandie Univ, DYNAMICURE UMR 1311, CHU Rouen, F-76000, Rouen, France
| | - Julien Grosjean
- Department of Digital Health, CHU Rouen, F-76000, Rouen, France
- Laboratoire d'Informatique Médicale Et d'Ingénierie Des Connaissances en E-Santé (LIMICS), U1142, INSERM, Sorbonne Université, Paris, France
| | - Thomas Duflot
- Department of Pharmacology, Univ Rouen Normandie, INSERM, Normandie Univ, EnVI UMR1096, CHU Rouen, F-76000, Rouen, France.
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14
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Schmid S, Zimmermann K, Koch C, Mester P, Athanasoulas G, Buttenschoen J, Fleischmann D, Schlosser-Hupf S, Pavel V, Schilling T, Müller M, Kratzer A. Interprofessional Therapeutic Drug Monitoring of Piperacillin/Tazobactam Enhances Care for Patients with Acute-on-Chronic Liver Failure in the ICU: A Retrospective Observational Pilot Study. Antibiotics (Basel) 2025; 14:202. [PMID: 40001445 PMCID: PMC11851559 DOI: 10.3390/antibiotics14020202] [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: 12/24/2024] [Revised: 02/02/2025] [Accepted: 02/11/2025] [Indexed: 02/27/2025] Open
Abstract
Background: Acute-on-chronic liver failure (ACLF) is a severe, rapidly progressing syndrome in patients with liver cirrhosis, often triggered by bacterial infections. Piperacillin/Tazobactam is a key antibiotic in this setting, and therapeutic drug monitoring (TDM) helps optimize its dosing. This study evaluates the impact of an interprofessional TDM strategy for Piperacillin/Tazobactam in ACLF patients in the ICU. Methods: This retrospective ICU study evaluated an interprofessional TDM approach for optimizing Piperacillin/Tazobactam dosing in critically ill ACLF patients. The team, consisting of physicians, clinical pharmacists, and staff nurses, engaged in shared decision making, collaboratively interpreting TDM results and adjusting the dosing accordingly. This study included 26 patients with ACLF who underwent initial TDM and 7 who received follow-up TDM. Piperacillin/Tazobactam dosing was modified based on TDM recommendations, with serum concentrations measured weekly. Adherence to and the implementation of interprofessional dosing recommendations were systematically analyzed to assess the impact of this approach. Results: The initial TDM showed that 30.8% of patients had Piperacillin/Tazobactam levels within the target range, while 53.8% were above and 15.4% below. The interprofessional team recommended dose reductions in seven patients, increases in three, and no change in eleven, with five requiring antibiotic modifications. At the first follow-up TDM, 20.0% reached target levels, while 80.0% remained above, with no subtherapeutic cases. The team recommended one further dose reduction and maintained dosing in four patients. All recommendations were fully implemented, demonstrating strong adherence to the collaborative protocol. Conclusions: The interprofessional TDM strategy optimized Piperacillin/Tazobactam dosing in ACLF patients with full adherence to the recommendations. This collaborative approach improves outcomes and supports global efforts to curb antibiotic resistance.
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Affiliation(s)
- Stephan Schmid
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Katharina Zimmermann
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Chiara Koch
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Patricia Mester
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Georgios Athanasoulas
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Jonas Buttenschoen
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Daniel Fleischmann
- Hospital Pharmacy, University Hospital Regensburg, 93053 Regensburg, Germany; (D.F.); (A.K.)
| | - Sophie Schlosser-Hupf
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Vlad Pavel
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Tobias Schilling
- Department of Interdisciplinary Acute, Emergency and Intensive Care Medicine (DIANI), Klinikum Stuttgart, 70174 Stuttgart, Germany;
| | - Martina Müller
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology, Rheumatology, and Infectious Diseases, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany; (K.Z.); (C.K.); (P.M.); (G.A.); (J.B.); (S.S.-H.); (V.P.); (M.M.)
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, 93053 Regensburg, Germany; (D.F.); (A.K.)
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15
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Nguyen VD, Côté A, Marsot A. External Evaluation of Longitudinal Population Pharmacokinetic Models of Vancomycin in Patients With Osteoarticular Infections. Ther Drug Monit 2025:00007691-990000000-00316. [PMID: 39937437 DOI: 10.1097/ftd.0000000000001303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 12/04/2024] [Indexed: 02/13/2025]
Abstract
BACKGROUND Osteoarticular infections pose a challenge for therapeutic drug monitoring of vancomycin because they often require prolonged treatment. Given the extensive renal elimination of vancomycin, its pharmacokinetic properties are difficult to predict in the later stages of treatment because the risk of nephrotoxicity increases with the duration of treatment. In this study, published longitudinal population pharmacokinetic (popPK) models were externally evaluated in a cohort of patients with osteoarticular infections. METHODS A literature search was performed in PubMed/EMBASE and published reviews. The predictive performance of the selected models was assessed through prediction- and simulation-based diagnostics using NONMEM software. Data were collected during both the retrospective and prospective phases, during which prospectively recruited patients provided additional vancomycin concentrations. RESULTS The external validation dataset comprised 525 vancomycin concentrations obtained from 73 patients treated for osteoarticular infections at Montréal General Hospital. Two published popPK models that provided different approaches for integrating a longitudinal structure were identified. Both failed to meet the clinically acceptable threshold of imprecision in population predictions. The weighted median absolute prediction error ranged from 34.9% to 48.3% before re-estimation of model parameters and from 33.5% to 35.2% after re-estimation. The re-estimated models tended to underpredict vancomycin concentrations in the later stages of treatment. CONCLUSIONS The 2 evaluated models showed poor predictive performance in our local study population. Further studies should explore new strategies to incorporate a longitudinal component and consider other relevant clinical covariates to develop improved longitudinal popPK models for vancomycin.
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Affiliation(s)
- Van Dong Nguyen
- Pharmacy Department, McGill University Health Centre, Montréal, Quebec, Canada
- Université de Montréal, Pavillon Jean-Coutu, Montréal, Quebec, Canada
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, Montréal, Quebec, Canada; and
| | - Alice Côté
- Pharmacy Department, McGill University Health Centre, Montréal, Quebec, Canada
- Université de Montréal, Pavillon Jean-Coutu, Montréal, Quebec, Canada
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, Montréal, Quebec, Canada; and
| | - Amélie Marsot
- Université de Montréal, Pavillon Jean-Coutu, Montréal, Quebec, Canada
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Pavillon Jean-Coutu, Montréal, Quebec, Canada; and
- Centre de recherche du CHU Ste-Justine, Centre hospitalier universitaire Ste-Justine, Montréal, Quebec, Canada
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16
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De Antonio-Cuscó M, Sorlí L, Muñoz-Bermúdez R, López-Mula C, Parrilla FJ, Gracia-Arnillas MP, Prim N, Campillo Ambrós N, Horcajada JP, Masclans-Enviz JR, Grau S, Luque S. Penetration of linezolid into the pleural cavity in critically ill patients with proven or suspected Gram-positive bacterial infections: a retrospective pharmacokinetic study. J Antimicrob Chemother 2025; 80:554-562. [PMID: 39723624 DOI: 10.1093/jac/dkae444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 11/29/2024] [Indexed: 12/28/2024] Open
Abstract
OBJECTIVES To describe the pharmacokinetics (PK) of linezolid in plasma and pleural fluid (PF) in critically ill patients with proven or suspected Gram-positive bacterial infections. PATIENTS AND METHODS Observational PK study in 14 critically ill patients treated with linezolid at standard doses. Blood and PF samples were collected and analysed by HPLC. The ratio between PF and plasma concentrations was calculated. The PK/pharmacodynamic (PD) target of linezolid in plasma was defined as 100% of the duration of the dosing interval in which concentrations were above the MIC (%100 T > MIC). RESULTS The median (5th and 95th percentiles) linezolid concentration values for plasma pre-dose at steady state (Cmin,ss) and at the end of the 1-h infusion at steady state (Cmax,ss) were 1.1 (0.02-28.3) and 13.8 mg/L (2.9-38.1), respectively, and the PF pre-dose concentration (PF0 h) and PF concentration at the end of the 1-h intravenous infusion (PF1 h) were 2.8 (0.1-31.6) and 4.2 mg/L (0.1-45.2), respectively. At both times (pre-dose and post-infusion), a strong positive correlation was observed between PF and plasma linezolid concentrations (Spearman's rho coefficients = 0.8 and 0.9, with P < 0.001 for both). The defined PK/PD target in plasma was achieved in 8 (57.1%), 4 (28.6%) and 3 (21.4%) patients assuming an MIC of 1, 2 and 4 mg/L, respectively. CONCLUSIONS Linezolid seems to penetrate well into the PF, with concentrations exceeding those in plasma. However, high inter-individual variability, both in plasma and PF concentrations, was observed. A high proportion of patients did not achieve the PK/PD target in plasma, especially in the presence of high MIC strains.
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Affiliation(s)
| | - Luisa Sorlí
- Infectious Diseases Department, Hospital del Mar, Barcelona, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d' Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Rosana Muñoz-Bermúdez
- Critical Care Department, Hospital del Mar, Hospital del Mar, Spain
- Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | - Francisco José Parrilla
- Critical Care Department, Hospital del Mar, Hospital del Mar, Spain
- Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Maria Pilar Gracia-Arnillas
- Critical Care Department, Hospital del Mar, Hospital del Mar, Spain
- Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Núria Prim
- Laboratori de Referència de Catalunya, Department of Microbiology, Barcelona, Spain
| | | | - Juan P Horcajada
- Infectious Diseases Department, Hospital del Mar, Barcelona, Spain
- Laboratori de Referència de Catalunya, Department of Microbiology, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d' Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Joan Ramon Masclans-Enviz
- Critical Care Department, Hospital del Mar, Hospital del Mar, Spain
- Critical Illness Research Group (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Barcelona, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d' Investigacions Mèdiques (IMIM), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
| | - Sònia Luque
- Pharmacy Department, Hospital del Mar, Barcelona, Spain
- CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d' Investigacions Mèdiques (IMIM), Barcelona, Spain
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17
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Toko H, Ogino M, Nishiwaki A, Kojina M, Aiba T. An Underlying Mechanism for the Altered Hypoglycemic Effects of Nateglinide in Rats with Acute Peripheral Inflammation. Biol Pharm Bull 2025; 48:51-59. [PMID: 39880623 DOI: 10.1248/bpb.b24-00582] [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] [Indexed: 01/31/2025]
Abstract
The hypoglycemic effects of nateglinide (NTG) were examined in rats with acute peripheral inflammation (API) induced by carrageenan treatment, and the mechanisms accounting for altered hypoglycemic effects were investigated. NTG was administered through the femoral vein in control and API rats, and its plasma concentration profile was characterized. The time courses of the changes in plasma glucose and insulin levels were also examined. Although the plasma concentration profile of NTG in API rats was marginally distinguishable from that in control rats, the hypoglycemic effect of NTG was more persistent in API rats than in control rats. In addition, NTG elevated the plasma level of insulin more intensely in API rats than in control rats. Then, the islets of Langerhans were procured by perfusing the pancreas with collagenase solution in control and API rats, and the pancreatic mRNA expression of preproinsulin (Ins1), as well as that of sulfonylurea receptor ABCC8 (Abcc8), were examined. As a result, the expression of preproinsulin and ABCC8 mRNA increased in API rats. These findings suggest that the hypoglycemic effect of NTG was potentiated in API rats due to increased insulin secretion in the pancreas, which was caused by enhanced preproinsulin synthesis and expression of the sulfonylurea receptor.
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Affiliation(s)
- Haruka Toko
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
| | - Manami Ogino
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
| | - Akane Nishiwaki
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
| | - Moeko Kojina
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
| | - Tetsuya Aiba
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama 700-8558, Japan
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18
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Zamoner W, de Souza Cavalcante R, Balbi AL, Ponce D. Vancomycin administration and AUC/MIC in patients with acute kidney injury on hemodialysis (HD): randomized clinical trial. Sci Rep 2024; 14:31220. [PMID: 39732984 DOI: 10.1038/s41598-024-82587-1] [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: 08/09/2024] [Accepted: 12/06/2024] [Indexed: 12/30/2024] Open
Abstract
The pharmacokinetics and pharmacodynamics (PK/PD) of vancomycin change during HD, increasing the risk of subtherapeutic concentrations. The aim of this study was to evaluate during and after the conventional and prolonged hemodialysis sessions to identify the possible risk of the patient remaining without adequate antimicrobial coverage during therapy. Randomized, non-blind clinical trial, including critically ill adults with septic AKI on conventional (4 h) and prolonged HD (6 and 10 h) and using vancomycin for at least 72 h. Sessions were analyzed and randomized into three groups (G): control (C), dose of 15 mg/kg after session), intervention (I) 2 h (dose of 7.5 mg/kg in the second hour and 7.5 mg/kg after) and IG continuous infusion (dose of 30 mg/kg in 24 h). Of the 316 patients recruited, 87 were randomized, and 174 HD sessions were monitored. For the analysis, 28 sessions belonged to the CG, 47 to the 2-hour IG, and 31 to the continuous IG. The groups were similar in age, weight, severity scores, use of nephrotoxins, sérum albumin, Kt/V, HD modality, ultrafiltration, and intradialytic intercurrences. The intervention groups showed a higher therapeutic concentration frequency than the control group (p < 0.002). The initial concentration was identified as a risk factor (OR 1.16, p = 0.001) for a non-therapeutic vancomycin concentration in the logistic regression. In contrast, the 2-hour IG was identified as a protective factor (OR 0.24, p = 0.04). Administration of vancomycin during dialysis proved to be a protective factor against concentrations outside the therapeutic target. Further studies are needed to suggest more appropriate doses of vancomycin for patients with AKI on dialysis therapy and to assess the impact of these results on clinical outcomes.
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Affiliation(s)
- Welder Zamoner
- Internal Medicine Department - Nephrology, Botucatu School of Medicine, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil.
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil.
| | - Ricardo de Souza Cavalcante
- Infectious Disease Department, Botucatu School of Medicine, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil
| | - André Luis Balbi
- Internal Medicine Department - Nephrology, Botucatu School of Medicine, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil
| | - Daniela Ponce
- Internal Medicine Department - Nephrology, Botucatu School of Medicine, University São Paulo State-UNESP, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil
- Clinics Hospital - Botucatu School of Medicine, District of Rubiao Junior, Botucatu, Sao Paulo, Brazil
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19
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König C, Frey O, Himmelein S, Mulack L, Brinkmann A, Perez Ruiz de Garibay A, Bingold T. In vitro elimination of antimicrobials during ADVanced Organ Support hemodialysis. Front Pharmacol 2024; 15:1447511. [PMID: 39737068 PMCID: PMC11682888 DOI: 10.3389/fphar.2024.1447511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 11/22/2024] [Indexed: 01/01/2025] Open
Abstract
Background Acute kidney injury (AKI) requiring continuous renal replacement therapy is common in critically ill patients. The ADVanced Organ Support (ADVOS) system is a novel hemodialysis machine that uses albumin enriched dialysate which allows the removal of protein-bound toxins and drugs. To date, data on antimicrobial removal under ADVOS has not yet been reported. Methods An in vitro study was conducted using whole porcine blood and continuous infusions of different antimicrobial agents to investigate the effect of ADVOS on drug exposure. Drugs with varying protein binding, molecular weights and renal clearances, anidulafungin, cefotaxime, daptomycin, fluconazole, ganciclovir, linezolid, meropenem and piperacillin were studied. Results All studied drugs were removed during the in vitro ADVOS experiment. Clearance under ADVOS (CLADVOS) for low protein-bound drugs, such as cefotaxime, fluconazole, ganciclovir, linezolid, meropenem and piperacillin ranged from 2.74 to 3.4 L/h at a blood flow of 100 mL/min. With a doubling of flow rate CL for these drugs increased. Although efficiently removed, this effect was not seen for CLADVOS in high protein-bound substances such as daptomycin (1.36 L/h) and anidulafungin (0.84 L/h). Conclusion The ADVOS system effectively removed protein-bound and unbound antimicrobials to a significant extent indicating that dose adjustments are required. Further, clinical studies are necessary to comprehensively assess the impact of ADVOS on antimicrobial drug removal. Until clinical data are available, therapeutic drug monitoring should guide antimicrobial dosing under ADVOS.
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Affiliation(s)
- Christina König
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, United States
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | | | - Lisa Mulack
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Brinkmann
- Department of Anesthesiology, Special Pain Management and Intensive Care Medicine, Heidenheim General Hospital, Heidenheim, Germany
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20
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Jackson D, Ulldemolins M, Liu X, Harris C, Tognolini A, Wallis SC, Sumi C, Parker SL, Eley V, Roberts JA. Continuous infusion of piperacillin/tazobactam optimizes intraoperative antibiotic exposure in patients undergoing elective pelvic exenteration surgery. Antimicrob Agents Chemother 2024; 68:e0111624. [PMID: 39480073 PMCID: PMC11619375 DOI: 10.1128/aac.01116-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2024] [Accepted: 10/03/2024] [Indexed: 11/02/2024] Open
Abstract
Patients undergoing elective pelvic exenteration surgery who receive piperacillin/tazobactam as surgical prophylaxis are at risk of suboptimal intraoperative antibiotic exposure. With this work, we aimed to study the plasma pharmacokinetics of piperacillin and tazobactam in this population to provide dosing recommendations that optimize antibiotic exposure. We developed a prospective, observational, pharmacokinetic study of piperacillin/tazobactam in patients undergoing pelvic exenteration. Population pharmacokinetic analysis and Monte Carlo simulations were performed with Monolix and Simulx software. Probabilities of target attainment of different dosing regimens against the minimum inhibitory concentration (MIC) breakpoints (8 and 16 mg/L) were calculated. Twelve patients were included in the study, with a median age of 50.0 years [interquartile interval (45.3-57.5)] and a median weight of 79.0 kg (61.3-88.3). Median surgical time was 10.5 h (9.8-11.7). A two-compartment linear model best fitted piperacillin and tazobactam data (190 plasma samples). Monte Carlo simulations showed that a lower dose of 2 g/0.25 g loading dose followed by 4 g/0.5 g q8h by continuous infusion provided ≥90% probability of target attainment for MIC = 16 mg/L for most of the patients. For non-continuous infusion regimens, only the 2-hourly bolus re-dosing achieved intraoperative concentrations of piperacillin ≥16 mg/L. Patients with weights ≥ 100 kg and glomerular filtration rates ≥ 120 mL/min required 4 g/0.5 g q6h by continuous infusion after a loading dose. In conclusion, continuous infusion of lower doses of piperacillin/tazobactam is as adequate as the 2-hourly re-dosing recommended by the current guidelines for surgical prophylaxis in pelvic exenteration. Patients with higher weights and glomerular filtration rates are at greater risk of inadequate exposure.
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Affiliation(s)
- Dwane Jackson
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Faculty of Medical and Health Sciences, University of the Sunshine Coast, Sippy Downs, Australia
| | - Marta Ulldemolins
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Infectious Diseases, Hospital del Mar, Barcelona, Spain
| | - Xin Liu
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Craig Harris
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Surgery, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Angela Tognolini
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Steven C. Wallis
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Chandra Sumi
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Suzanne L. Parker
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Victoria Eley
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A. Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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21
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Mohamed Shukri NRI, Hassan SK, Md Noor SS, Ab Hamid SA, Nik Mohamad NA, Wan Muhd Shukeri WF, Mazlan MZ. The Outcome of Hospital-Acquired Bloodstream Infection and Its Associated Factors in Critical Care Unit. Malays J Med Sci 2024; 31:160-177. [PMID: 39830098 PMCID: PMC11740822 DOI: 10.21315/mjms2024.31.6.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 08/16/2024] [Indexed: 01/22/2025] Open
Abstract
Background Hospital-acquired bloodstream infections (BSI) are associated with high morbidity and mortality rates. This study was conducted to describe the outcomes and the prognosis of hospital-acquired BSI in the Critical Care Unit, Hospital Pakar Universiti Sains Malaysia (HPUSM), as well as to identify associated factors of treatment failure and mortality at 28 days. Methods This prospective cohort study was conducted in the Critical Care Unit of HPUSM from September 2019 to March 2021. Eligible participants included patients with a positive blood culture recorded after 48 hours of admission to hospital. Results There was a total of 250 patients, whose positive blood cultures were isolated. The main isolated organisms were Klebsiella pneumonia (23.6%), Pseudomonas spp. (19.2%), Escherichia coli (12.8%) and Acinetobacter sp. (9.2%). The mortality of hospital-acquired BSI was 27.6%. Multiple logistic regression analysis revealed that age [adjusted odds ratio (OR) = 1.06; 95% confidence interval (CI): 1.03, 1.09; p < 0.001], cases with extended-spectrum beta-lactamases (ESBL) (adjusted OR = 5.57; 95% CI: 2.04, 15.21; p = 0.001), with multidrug-resistant (MDR) organisms (adjusted OR = 14.70; 95% CI: 3.97, 54.48; p < 0.001) and those with a sequential organ failure assessment (SOFA) score > 11 (adjusted OR = 4.16; 95% CI: 1.31, 13.19; p = 0.015) had statistically significant associations with treatment failure. Factors significantly associated with 28-day mortality included age (adjusted OR: 1.06: 95% CI; 1.03, 1.09; p < 0.001), MDR organisms (adjusted OR = 14.70; 95% CI: 3.97, 54.48; p < 0.001) and SOFA score > 11 (adjusted OR = 4.16; 95% CI: 1.31, 13.19; p = 0.015). Conclusion The elderly, ESBL, MDR organisms and high SOFA scores were associated with treatment failure and 28-day mortality in hospital-acquired BSI.
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Affiliation(s)
| | - Shamsul Kamalrujan Hassan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital Pakar Universiti Sains Malaysia, Kelantan, Malaysia
| | - Siti Suraiya Md Noor
- Hospital Pakar Universiti Sains Malaysia, Kelantan, Malaysia
- Department Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Siti Azrin Ab Hamid
- Hospital Pakar Universiti Sains Malaysia, Kelantan, Malaysia
- Biostatistics and Research Methodology Unit, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Nik Abdullah Nik Mohamad
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital Pakar Universiti Sains Malaysia, Kelantan, Malaysia
| | - Wan Fadzlina Wan Muhd Shukeri
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital Pakar Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mohd Zulfakar Mazlan
- Department of Anaesthesiology and Intensive Care, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
- Hospital Pakar Universiti Sains Malaysia, Kelantan, Malaysia
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22
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Nielsen MBD, Jørgensen AR, Stilling M, Mikkelsen MKD, Jørgensen NP, Bue M. Dynamic distribution of systemically administered antibiotics in orthopeadically relevant target tissues and settings. APMIS 2024; 132:992-1025. [PMID: 39530161 PMCID: PMC11582342 DOI: 10.1111/apm.13490] [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: 08/29/2024] [Accepted: 10/22/2024] [Indexed: 11/16/2024]
Abstract
This review aimed to summarize the current literature on antibiotic distribution in orthopedically relevant tissues and settings where dynamic sampling methods have been used. PubMed and Embase databases were systematically searched. English-published studies between 2004 and 2024 involving systemic antibiotic administration in orthopedically relevant tissues and settings based on dynamic measurements were included. In total, 5385 titles were identified. After title and abstract screening, 97 eligible studies (43 different antibiotic drugs) were included. The studies covered both preclinical (42%) and clinical studies including healthy and infected tissues (21%) and prophylactic and steady-state situations (35%). Microdialysis emerged as the predominant sampling method in 98% of the studies. Most of the presented antibiotics (80%) were only assessed once or twice. Among the most extensively studied antibiotics were cefuroxime (18 studies), linezolid (9 studies) and vancomycin (9 studies). This review presents valuable insights into the microenvironmental distribution of antibiotics in orthopedically relevant target tissues and settings and seeks to provide a basis for improving dosing recommendations and treatment outcomes. However, it is important to acknowledge that our findings are limited to the specific drug, dosing regimens, administration method and target tissue, and are crucially linked to the selected PK/PD target.
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Affiliation(s)
- Maria Bech Damsgaard Nielsen
- Department of Clinical MedicineAarhus UniversityAarhus NDenmark
- Aarhus Denmark Microdialysis Research (ADMIRE)Orthopaedic Research Laboratory, Aarhus University HospitalAarhus NDenmark
| | - Andrea René Jørgensen
- Department of Clinical MedicineAarhus UniversityAarhus NDenmark
- Aarhus Denmark Microdialysis Research (ADMIRE)Orthopaedic Research Laboratory, Aarhus University HospitalAarhus NDenmark
| | - Maiken Stilling
- Department of Clinical MedicineAarhus UniversityAarhus NDenmark
- Aarhus Denmark Microdialysis Research (ADMIRE)Orthopaedic Research Laboratory, Aarhus University HospitalAarhus NDenmark
- Department of Orthopaedic SurgeryAarhus University HospitalAarhus NDenmark
| | - Mads Kristian Duborg Mikkelsen
- Department of Clinical MedicineAarhus UniversityAarhus NDenmark
- Aarhus Denmark Microdialysis Research (ADMIRE)Orthopaedic Research Laboratory, Aarhus University HospitalAarhus NDenmark
| | | | - Mats Bue
- Department of Clinical MedicineAarhus UniversityAarhus NDenmark
- Aarhus Denmark Microdialysis Research (ADMIRE)Orthopaedic Research Laboratory, Aarhus University HospitalAarhus NDenmark
- Department of Orthopaedic SurgeryAarhus University HospitalAarhus NDenmark
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23
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Li L, Zinger J, Sassen SDT, Juffermans NP, Koch BCP, Endeman H. The relation between inflammatory biomarkers and drug pharmacokinetics in the critically ill patients: a scoping review. Crit Care 2024; 28:376. [PMID: 39563441 PMCID: PMC11577668 DOI: 10.1186/s13054-024-05150-4] [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: 08/09/2024] [Accepted: 10/26/2024] [Indexed: 11/21/2024] Open
Abstract
BACKGROUND The level of inflammation alters drug pharmacokinetics (PK) in critically ill patients. This might compromise treatment efficacy. Understanding the specific effects of inflammation, measured by biomarkers, on drug absorption, distribution, metabolism, and excretion is might help in optimizing dosing strategies. OBJECTIVES This review investigates the relationship between inflammatory biomarkers and PK parameters absorption, distribution, metabolism and excretion (ADME) in critically ill patients, providing insight in the complexity of dosing drugs in critically ill patients. METHOD Following PRISMA guidelines, we conducted a comprehensive search of Medline, Embase, Web of Science, and Cochrane databases (January 1946-November 2023). Studies examining inflammatory biomarkers, PK parameters, or drug exposure in critically ill patients were included. Records were screened by title, abstract, and full text, with any discrepancies resolved through discussion or consultation with a third reviewer. RESULTS Of the 4479 records screened, 31 met our inclusion criteria: 2 on absorption, 7 on distribution, 17 on metabolism, and 6 on excretion. In general, results are only available for a limited number of drugs, and most studies are done only looking at one of the components of ADME. Higher levels of inflammatory biomarkers may increase or decrease drug absorption depending on whether the drug undergoes hepatic first-pass elimination. For drug distribution, inflammation is negatively correlated with drug protein binding capacity, positively correlated with cerebrospinal fluid penetration, and negatively correlated with peritoneal penetration. Metabolizing capacity of most drugs was inversely correlated with inflammatory biomarkers. Regarding excretion, inflammation can lead to reduced drug clearance, except in the neonatal population. CONCLUSION Inflammatory biomarkers can offer valuable information regarding altered PK in critically ill patients. Our findings emphasize the need to consider inflammation-driven PK variability when individualizing drug therapy in this setting, at the same time research is limited to certain drugs and needs further research, also including pharmacodynamics.
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Affiliation(s)
- Letao Li
- Department of Hospital Pharmacy, Erasmus MC-University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Xinqiao Hospital, Army Medical University, 183 Xinqiao Street, Shapingba District, Chongqing, 400037, China
| | - Julia Zinger
- Department of Hospital Pharmacy, Erasmus MC-University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Sebastiaan D T Sassen
- Department of Hospital Pharmacy, Erasmus MC-University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, Erasmus MC-University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC-University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Henrik Endeman
- Department of Intensive Care, Erasmus MC-University Medical Center, Doctor Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
- Department of Intensive Care, OLVG, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.
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24
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Hui LA, Bodolea C, Popa A, Vlase AM, Hirișcău EI, Vlase L. Linezolid Pharmacokinetics in Critically Ill Patients: Continuous Versus Intermittent Infusion. Antibiotics (Basel) 2024; 13:961. [PMID: 39452227 PMCID: PMC11504488 DOI: 10.3390/antibiotics13100961] [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: 08/28/2024] [Revised: 09/29/2024] [Accepted: 10/07/2024] [Indexed: 10/26/2024] Open
Abstract
BACKGROUND Linezolid has been found to have considerable interindividual variability, especially in critically ill patients, which can lead to suboptimal plasma concentration. To overcome this shortcoming, several solutions have been proposed. These include using loading dose, higher maintenance doses, and dose stratification according to the patient's particularities, therapeutic drug monitoring, and drug administration via continuous infusion (CI) instead of intermittent infusion (II). In the present study, we aim to compare the pharmacokinetic (PK) parameters of linezolid after administration as II versus CI to critically ill patients. METHODS In a prospective study conducted in an intensive care unit, we compared the same two daily doses of linezolid administered via II versus CI. The serum concentration was measured, and pharmacokinetic parameters were calculated. The pharmacokinetic/pharmacodynamic (PK/PD) indices for efficacy chosen were area under the concentration-time curve at steady state divided by the minimum inhibitory concentration over 80 (AUC24-48/MIC > 80). RESULTS Greater serum concentration variability was observed in the II group than in the CI group. The %T > MIC > 80% was achieved for MICs of 1 and 2 µg/mL 100% of the time, whereas for the II group, this was 93% and 73%, respectively. AUC24-48/MIC > 80 was reached in 100% of cases in the CI group compared with 87% in the II group for a MIC of 1 µg/mL. CONCLUSIONS The two infusion methods may be used comparably, but utilizing CI as an alternative to II may have potential benefits, including avoiding periods of suboptimal concentrations, which may enhance safety profiles and clinical outcomes. Considering the relatively few studies performed on linezolid to date, which are increasing in number, the results of the present study may be of interest.
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Affiliation(s)
- Ligia-Ancuța Hui
- Pharmaceutical Technology and Biopharmacy Department, Faculty of Pharmacy, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania; (L.-A.H.); (L.V.)
- ICU Department, University Clinical Municipal Hospital, 400139 Cluj-Napoca, Romania; (C.B.); (E.I.H.)
| | - Constantin Bodolea
- ICU Department, University Clinical Municipal Hospital, 400139 Cluj-Napoca, Romania; (C.B.); (E.I.H.)
- ICU Department, Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400006 Cluj-Napoca, Romania
| | - Adina Popa
- Clinical Pharmacy Department, Faculty of Pharmacy, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania
| | - Ana-Maria Vlase
- Pharmaceutical Botany Department, Faculty of Pharmacy, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania;
| | - Elisabeta Ioana Hirișcău
- ICU Department, University Clinical Municipal Hospital, 400139 Cluj-Napoca, Romania; (C.B.); (E.I.H.)
- Nursing Department, Faculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400089 Cluj-Napoca, Romania
| | - Laurian Vlase
- Pharmaceutical Technology and Biopharmacy Department, Faculty of Pharmacy, University of Medicine and Pharmacy “Iuliu Hatieganu”, 400012 Cluj-Napoca, Romania; (L.-A.H.); (L.V.)
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Rando E, Novy E, Sangiorgi F, De Pascale G, Fantoni M, Murri R, Roberts JA, Cotta MO. A Systematic Review of the Pharmacokinetics and Pharmacodynamics of Novel Beta-Lactams and Beta-Lactam with Beta-Lactamase Inhibitor Combinations for the Treatment of Pneumonia Caused by Carbapenem-Resistant Gram-Negative Bacteria. Int J Antimicrob Agents 2024; 64:107266. [PMID: 38971203 DOI: 10.1016/j.ijantimicag.2024.107266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/18/2024] [Accepted: 07/01/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Novel beta-lactams show activity against many multidrug-resistant Gram-negative bacteria that cause severe lung infections. Understanding pharmacokinetic/pharmacodynamic characteristics of these agents may help optimise outcomes in the treatment of pneumonia. OBJECTIVES To describe and appraise studies that report pulmonary pharmacokinetic and pharmacodynamic data of cefiderocol, ceftazidime/avibactam, ceftolozane/tazobactam, imipenem/cilastatin/relebactam and meropenem/vaborbactam. METHODS MEDLINE (PubMed), Embase, Web of Science and Scopus libraries were used for the literature search. Pulmonary population pharmacokinetic and pharmacokinetic/pharmacodynamic studies on adult patients receiving cefiderocol, ceftazidime/avibactam, ceftolozane/tazobactam, imipenem/cilastatin/relebactam, and meropenem/vaborbactam published in peer-reviewed journals were included. Two independent authors screened, reviewed and extracted data from included articles. A reporting guideline for clinical pharmacokinetic studies (ClinPK statement) was used for bias assessment. Relevant outcomes were included, such as population pharmacokinetic parameters and probability of target attainment of dosing regimens. RESULTS Twenty-four articles were included. There was heterogeneity in study methods and reporting of results, with diversity across studies in adhering to the ClinPK statement checklist. Ceftolozane/tazobactam was the most studied agent. Only two studies collected epithelial lining fluid samples from patients with pneumonia. All the other phase I studies enrolled healthy subjects. Significant population heterogeneity was evident among available population pharmacokinetic models. Probabilities of target attainment rates above 90% using current licensed dosing regiments were reported in most studies. CONCLUSIONS Although lung pharmacokinetics was rarely described, this review observed high target attainment using plasma pharmacokinetic data for all novel beta-lactams. Future studies should describe lung pharmacokinetics in patient populations at risk of carbapenem-resistant pathogen infections.
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Affiliation(s)
- Emanuele Rando
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Emmanuel Novy
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Department of Anaesthesiology, Critical Care and Perioperative Medicine, Nancy University Hospital, Nancy, France; SIMPA, Université de Lorraine, Vandoeuvre les Nancy, France
| | - Flavio Sangiorgi
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienza dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Massimo Fantoni
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy; Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Rita Murri
- Dipartimento di Sicurezza e Bioetica - Sezione di Malattie Infettive, Università Cattolica del Sacro Cuore, Rome, Italy; Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia; Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Menino Osbert Cotta
- Department of Anaesthesiology, Critical Care and Perioperative Medicine, Nancy University Hospital, Nancy, France; Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
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26
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Michihara A, Hanada M, Nagatsuka Handa Y, Mizoguchi T, Ohchi Y, Sato Y. Change of dexmedetomidine and midazolam concentrations by simultaneous injection in an in vitro extracorporeal circuit. Perfusion 2024; 39:1222-1230. [PMID: 37325845 DOI: 10.1177/02676591231184715] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE Patient sedation and analgesia are vital for safety and comfort during extracorporeal membrane oxygenation (ECMO). However, adsorption by the circuit may alter drug pharmaco-kinetics and remains poorly characterized. This study is the first to examine the concentrations of DEX and MDZ in the presence of drug-drug interactions using an in vitro extracorporeal circuit system that incorporates a polymer-coated polyvinyl chloride tube, but not a membrane oxygenator. METHODS AND RESULTS Nine in vitro extracorporeal circuits were prepared using polymer-coated PVC tubing. Once the circuits were primed and running, either a single drug or two drugs were injected as boluses into the circuit with three circuits per drug. Drug samples were drawn following injection at 2, 5, 15, 30, 60, and 120 min and at 4, 12, and 24 h. They were then analyzed using high-performance liquid chromatography with mass spectrometry. When compared with an injection of DEX alone, the combination of DEX and MDZ is highly changed, with DEX and MDZ affecting the availability of free drugs in the circuit. CONCLUSIONS The change of DEX and MDZ concentrations was confirmed by a combination of both drugs as compared with either single-infusion DEX or MDZ in an in vitro extracorporeal circuit. Drug-drug interactions developed between DEX and MDZ through albumin in an extracorporeal circuit; as a result, the unbounded drugs might change in the circuit.
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Affiliation(s)
- Ayana Michihara
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Miyu Hanada
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Yuka Nagatsuka Handa
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
| | - Takayuki Mizoguchi
- Department of Clinical Engineering, Oita University Hospital, Yufu-shi, Japan
| | - Yoshifumi Ohchi
- Department of Intensive Care Unit, Oita University Hospital, Yufu-shi, Japan
| | - Yuhki Sato
- Department of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Fukuyama University, Fukuyama-shi, Japan
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Hîncu S, Apetroaei MM, Ștefan G, Fâcă AI, Arsene AL, Mahler B, Drăgănescu D, Tăerel AE, Stancu E, Hîncu L, Zamfirescu A, Udeanu DI. Drug-Drug Interactions in Nosocomial Infections: An Updated Review for Clinicians. Pharmaceutics 2024; 16:1137. [PMID: 39339174 PMCID: PMC11434876 DOI: 10.3390/pharmaceutics16091137] [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: 07/11/2024] [Revised: 08/26/2024] [Accepted: 08/26/2024] [Indexed: 09/30/2024] Open
Abstract
Prevention, assessment, and identification of drug-drug interactions (DDIs) represent a challenge for healthcare professionals, especially in nosocomial settings. This narrative review aims to provide a thorough assessment of the most clinically significant DDIs for antibiotics used in healthcare-associated infections. Complex poly-pharmaceutical regimens, targeting multiple pathogens or targeting one pathogen in the presence of another comorbidity, have an increased predisposition to result in life-threatening DDIs. Recognising, assessing, and limiting DDIs in nosocomial infections offers promising opportunities for improving health outcomes. The objective of this review is to provide clinicians with practical advice to prevent or mitigate DDIs, with the aim of increasing the safety and effectiveness of therapy. DDI management is of significant importance for individualising therapy according to the patient, disease status, and associated comorbidities.
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Affiliation(s)
- Sorina Hîncu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
- Fundeni Clinical Institute, 258, Fundeni Street, 022328 Bucharest, Romania
| | - Miruna-Maria Apetroaei
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
| | - Gabriela Ștefan
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
| | - Anca Ionela Fâcă
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
- Marius Nasta Institute of Pneumophthisiology, 90, Viilor Street, 050159 Bucharest, Romania;
| | - Andreea Letiția Arsene
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
- Marius Nasta Institute of Pneumophthisiology, 90, Viilor Street, 050159 Bucharest, Romania;
| | - Beatrice Mahler
- Marius Nasta Institute of Pneumophthisiology, 90, Viilor Street, 050159 Bucharest, Romania;
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8, Eroii Sanitari Street, 050474 Bucharest, Romania
| | - Doina Drăgănescu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
| | - Adriana-Elena Tăerel
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
| | - Emilia Stancu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
| | - Lucian Hîncu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
| | - Andreea Zamfirescu
- Faculty of Midwifery and Nursing, Carol Davila University of Medicine and Pharmacy, 8, Street, 050474 Bucharest, Romania;
| | - Denisa Ioana Udeanu
- Faculty of Pharmacy, Carol Davila University of Medicine and Pharmacy, 6, Traian Vuia Street, 020956 Bucharest, Romania; (S.H.); (G.Ș.); (A.I.F.); (A.L.A.); (D.D.); (A.-E.T.); (E.S.); (L.H.); (D.I.U.)
- Marius Nasta Institute of Pneumophthisiology, 90, Viilor Street, 050159 Bucharest, Romania;
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O'Hanlon CJ, Holford N, Anderson BJ, Greaves M, Blackburn L, Tingle MD, Hannam JA. A pharmacokinetic framework describing antibiotic adsorption to cardiopulmonary bypass devices. CPT Pharmacometrics Syst Pharmacol 2024; 13:1409-1421. [PMID: 38813588 PMCID: PMC11330180 DOI: 10.1002/psp4.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/19/2024] [Accepted: 05/14/2024] [Indexed: 05/31/2024] Open
Abstract
Cardiopulmonary bypass (CPB) can alter pharmacokinetic (PK) parameters and the drug may adsorb to the CPB device, altering exposure. Cefazolin is a beta-lactam antibiotic used for antimicrobial prophylaxis during cardiac surgery supported by CPB. Adsorption of cefazolin could result in therapeutic failure. An ex vivo study was undertaken using CPB devices primed and then dosed with cefazolin and samples were obtained over 1 hour of recirculation. Twelve experimental runs were conducted using different CPB device sizes (neonate, infant, child, and adult), device coatings (Xcoating™, Rheoparin®, PH.I.S.I.O), and priming solutions. The time course of saturable binding, using Bmax (binding capacity), Kd (dissociation constant), and T2off (half-time of dissociation), described cefazolin adsorption. Bmax estimates for the device sizes were neonate 40.0 mg (95% CI 24.3, 67.4), infant 48.6 mg (95% CI 5.97, 80.2), child 77.8 mg (95% CI 54.9, 103), and adult 196 mg (95% CI 191, 199). The Xcoating™ Kd estimate was 139 mg/L (95% CI 27.0, 283) and the T2off estimate was 98.4 min (95% CI 66.8, 129). The Rheoparin® and PH.I.S.I.O coatings had similar binding parameters with Kd and T2off estimates of 0.169 mg/L (95% CI 0.01, 1.99) and 4.94 min (95% CI 0.17, 59.4). The Bmax was small (< 10%) relative to a typical total patient dose during cardiac surgery supported by CPB. A dose adjustment for cefazolin based solely on drug adsorption is not required. This framework could be extended to other PK studies involving CPB.
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Affiliation(s)
- Conor J. O'Hanlon
- Department of Pharmacology & Clinical PharmacologyUniversity of AucklandAucklandNew Zealand
| | - Nick Holford
- Department of Pharmacology & Clinical PharmacologyUniversity of AucklandAucklandNew Zealand
| | - Brian J. Anderson
- Department of AnaesthesiologyUniversity of AucklandAucklandNew Zealand
- Department of AnaesthesiaAuckland City HospitalAucklandNew Zealand
| | - Mark Greaves
- Department of AnaesthesiaAuckland City HospitalAucklandNew Zealand
| | - Lee Blackburn
- Department of AnaesthesiologyUniversity of AucklandAucklandNew Zealand
| | - Malcolm D. Tingle
- Department of Pharmacology & Clinical PharmacologyUniversity of AucklandAucklandNew Zealand
| | - Jacqueline A. Hannam
- Department of Pharmacology & Clinical PharmacologyUniversity of AucklandAucklandNew Zealand
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29
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Dorofaeff T, Valero YG, Coulthard MG, Wallis SC, Chatfield MD, Lister P, Lipman J, Roberts JA, Parker SL. Can capillary microsampling facilitate a clinical pharmacokinetics study of cefazolin in critically ill children? Bioanalysis 2024; 16:873-881. [PMID: 39072476 PMCID: PMC11457676 DOI: 10.1080/17576180.2024.2377912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/05/2024] [Indexed: 07/30/2024] Open
Abstract
Aim: Pharmacokinetic studies in children are limited, in part due to challenges in blood sampling. We compare the use of capillary microsampling and conventional sampling techniques in pediatric patients to show results that can be used in the pharmacokinetic analysis of Cefazolin.Patients & Methods: Paired blood samples (n = 48) were collected from 12 patients (median age/weight 49 months/18 kg).Results: The United States Federal Drug Administration incurred sample reanalysis acceptance criteria was used and identified 79% of paired samples achieved a difference of less than 20% in magnitude with a capillary microsampling bias of -10% (SD 20%). With exclusion of PK outliers, this rose to 88%.Conclusion: Capillary microsampling is reliable, meets acceptance criteria and can be used in pharmacokinetic studies.ACTRN: 12618001469202.
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Affiliation(s)
- Tavey Dorofaeff
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia
- Department of Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, QLD 4101, Australia
| | - Yarmarly Guerra Valero
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia
| | - Mark G Coulthard
- Department of Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, QLD 4101, Australia
- Mayne Academy of Paediatrics, The University of Queensland, Brisbane, QLD 4101, Australia
| | - Steven C Wallis
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia
| | - Mark D Chatfield
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia
| | - Paula Lister
- Department of Paediatric Intensive Care, Sunshine Coast University Hospital, Sunshine Coast, QLD 4560,Australia
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD 4029, Australia
- Jamieson Trauma Institute, Royal Brisbane & Women's Hospital, Brisbane, QLD 4029, Australia
- Nimes University Hospital, University of Montpellier, Nimes, France
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD 4029, Australia
- Nimes University Hospital, University of Montpellier, Nimes, France
- Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, QLD 4029, Australia
| | - Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD 4029, Australia
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Rančić A, Milosavljević MN, Rosić N, Milovanović D, Folić M, Zečević DR, Petrović N, Čorbić MM, Dabanović V, Janković SM. Population pharmacokinetics of meropenem in critically ill patients. Open Med (Wars) 2024; 19:20241004. [PMID: 39070942 PMCID: PMC11278387 DOI: 10.1515/med-2024-1004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 05/11/2024] [Accepted: 07/08/2024] [Indexed: 07/30/2024] Open
Abstract
Objective The pharmacokinetics of meropenem are significantly altered in critically ill patients. A population pharmacokinetic study was designed to estimate typical values of meropenem clearance in critically ill patients and evaluate potential factors of influence. Methods After meropenem reached a steady state in each patient, two blood samples were taken within the dose interval. The one-compartment pharmacokinetic model based on the data from 101 intensive care unit patients was built using NONMEM software. Results Typical values of meropenem clearance and volume of distribution were 3.80 L/h and 3.52 L, respectively. In the final model, meropenem clearance was influenced by serum concentrations of creatinine (CRE), leukocyte count (WBC), hypertension (HTA), and concomitant use of vancomycin (VAN) or colistimethate (COL): CL (L/h) = 5.29 × CRE ^ 0.000001 × WBCs ^ (-0.165) + 0.000001 × HTA + 0.825 × VAN + 1.28 × COL. Conclusion In order to achieve effective plasma concentrations of meropenem in critically ill patients, the meropenem dosing regimen should be adjusted according to individual values of drug clearance.
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Affiliation(s)
| | - Miloš N. Milosavljević
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, Kragujevac, 34000, Serbia
| | - Nikola Rosić
- Clinical Pharmacology Department, University Clinical Centre Kragujevac, Kragujevac, Serbia
| | - Dragan Milovanović
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, Kragujevac, 34000, Serbia
| | - Marko Folić
- Department of Pharmacy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, 34000, Serbia
| | - Dejana Ružić Zečević
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, Kragujevac, 34000, Serbia
- Clinical Pharmacology Department, University Clinical Centre Kragujevac, Kragujevac, Serbia
| | - Nemanja Petrović
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, Kragujevac, 34000, Serbia
- Clinical Pharmacology Department, University Clinical Centre Kragujevac, Kragujevac, Serbia
| | | | - Vera Dabanović
- Pharmacy Institution of Montenegro “Montefarm”, Podgorica, Montenegro
| | - Slobodan M. Janković
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, Kragujevac, 34000, Serbia
- Clinical Pharmacology Department, University Clinical Centre Kragujevac, Kragujevac, Serbia
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31
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Dhanani JA, Shekar K, Parmar D, Lipman J, Bristow D, Wallis SC, Won H, Sumi CD, Abdul-Aziz MH, Roberts JA. COVID-19 Drug Treatments Are Prone to Sequestration in Extracorporeal Membrane Oxygenation Circuits: An Ex Vivo Extracorporeal Membrane Oxygenation Study. ASAIO J 2024; 70:546-552. [PMID: 38829573 DOI: 10.1097/mat.0000000000002120] [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: 06/05/2024] Open
Abstract
Drug treatments for coronavirus disease 2019 (COVID-19) dramatically improve patient outcomes, and although extracorporeal membrane oxygenation (ECMO) has significant use in these patients, it is unknown whether ECMO affects drug dosing. We used an ex vivo adult ECMO model to measure ECMO circuit effects on concentrations of specific COVID-19 drug treatments. Three identical ECMO circuits used in adult patients were set up. Circuits were primed with fresh human blood (temperature and pH maintained within normal limits). Three polystyrene jars with 75 ml fresh human blood were used as controls. Remdesivir, GS-441524, nafamostat, and tocilizumab were injected in the circuit and control jars at therapeutic concentrations. Samples were taken from circuit and control jars at predefined time points over 6 h and drug concentrations were measured using validated assays. Relative to baseline, mean (± standard deviation [SD]) study drug recoveries in both controls and circuits at 6 h were significantly lower for remdesivir (32.2% [±2.7] and 12.4% [±2.1], p < 0.001), nafamostat (21.4% [±5.0] and 0.0% [±0.0], p = 0.018). Reduced concentrations of COVID-19 drug treatments in ECMO circuits is a clinical concern. Remdesivir and nafamostat may need dose adjustments. Clinical pharmacokinetic studies are suggested to guide optimized COVID-19 drug treatment dosing during ECMO.
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Affiliation(s)
- Jayesh A Dhanani
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Dinesh Parmar
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, Queensland, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Womens Hospital
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Debra Bristow
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Steven C Wallis
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Hayoung Won
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Chandra D Sumi
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Mohd H Abdul-Aziz
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
| | - Jason A Roberts
- From the University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Jamieson Trauma Institute, Royal Brisbane and Womens Hospital
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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Samimi MN, Hale A, Schults J, Fischer A, Roberts JA, Dhanani J. Clinical guidance for unfractionated heparin dosing and monitoring in critically ill patients. Expert Opin Pharmacother 2024; 25:985-997. [PMID: 38825778 DOI: 10.1080/14656566.2024.2364057] [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: 01/29/2024] [Accepted: 05/31/2024] [Indexed: 06/04/2024]
Abstract
INTRODUCTION Unfractionated heparin is a widely used anticoagulant in critically ill patients. It has a well-established safety profile and remains an attractive option for clinicians due to its short half-life and reversibility. Heparin has a unique pharmacokinetic profile, which contributes to significant inter-patient and intra-patient variability in effect. The variability in anticoagulant effect combined with heparin's short half-life mean close monitoring is required for clinical efficacy and preventing adverse effects. To optimize heparin use in critically ill patients, effective monitoring assays and dose adjustment strategies are needed. AREAS COVERED This paper explores the use of heparin as an anticoagulant and optimal approaches to monitoring in critically ill patients. EXPERT OPINION Conventional monitoring assays for heparin dosing have significant limitations. Emerging data appear to favor using anti-Xa assay monitoring for heparin anticoagulation, which many centers have successfully adopted as the standard. The anti-Xa assay appears have important benefits relative to the aPTT for heparin monitoring in critically ill patients, and should be considered for broader use.
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Affiliation(s)
- May N Samimi
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew Hale
- Discipline of Pharmacy, School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Jessica Schults
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Andreas Fischer
- Pharmacy Department, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Jayesh Dhanani
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Radkowski P, Derkaczew M, Mazuchowski M, Moussa A, Podhorodecka K, Dawidowska-Fidrych J, Braczkowska-Skibińska M, Synia D, Śliwa K, Wiszpolska M, Majewska M. Antibiotic-Drug Interactions in the Intensive Care Unit: A Literature Review. Antibiotics (Basel) 2024; 13:503. [PMID: 38927170 PMCID: PMC11201170 DOI: 10.3390/antibiotics13060503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
Interactions between drugs are a common problem in Intensive Care Unit patients, as they mainly have a critical condition that often demands the administration of multiple drugs simultaneously. Antibiotics are among the most frequently used medications, as infectious diseases are often observed in ICU patients. In this review, the most important antibiotic-drug interactions, based on the pharmacokinetic and pharmacodynamic mechanisms, were gathered together and described. In particular, some of the most important interactions with main groups of antibacterial drugs were observed in patients simultaneously prescribed oral anticoagulants, NSAIDs, loop diuretics, and valproic acid. As a result, the activity of drugs can be increased or decreased, as dosage modification might be necessary. It should be noted that these crucial interactions can help predict and avoid negative consequences, leading to better patient recovery. Moreover, since there are other factors, such as fluid therapy or albumins, which may also modify the effectiveness of antibacterial therapy, it is important for anaesthesiologists to be aware of them.
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Affiliation(s)
- Paweł Radkowski
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland; (P.R.); (M.D.); (M.M.); (K.P.); (M.B.-S.); (D.S.); (K.Ś.)
- Hospital zum Heiligen Geist in Fritzlar, 34560 Fritzlar, Germany;
- Department of Anaesthesiology and Intensive Care, Regional Specialist Hospital in Olsztyn, 10-561 Olsztyn, Poland
| | - Maria Derkaczew
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland; (P.R.); (M.D.); (M.M.); (K.P.); (M.B.-S.); (D.S.); (K.Ś.)
| | - Michał Mazuchowski
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland; (P.R.); (M.D.); (M.M.); (K.P.); (M.B.-S.); (D.S.); (K.Ś.)
| | - Annas Moussa
- Hospital zum Heiligen Geist in Fritzlar, 34560 Fritzlar, Germany;
| | - Katarzyna Podhorodecka
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland; (P.R.); (M.D.); (M.M.); (K.P.); (M.B.-S.); (D.S.); (K.Ś.)
| | | | - Małgorzata Braczkowska-Skibińska
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland; (P.R.); (M.D.); (M.M.); (K.P.); (M.B.-S.); (D.S.); (K.Ś.)
| | - Daria Synia
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland; (P.R.); (M.D.); (M.M.); (K.P.); (M.B.-S.); (D.S.); (K.Ś.)
| | - Karol Śliwa
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland; (P.R.); (M.D.); (M.M.); (K.P.); (M.B.-S.); (D.S.); (K.Ś.)
| | - Marta Wiszpolska
- Department of Human Physiology and Pathophysiology, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland;
| | - Marta Majewska
- Department of Human Physiology and Pathophysiology, Faculty of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland;
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Sandes V, Figueras A, Lima EC. Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use-A Narrative Review. Antibiotics (Basel) 2024; 13:457. [PMID: 38786184 PMCID: PMC11117530 DOI: 10.3390/antibiotics13050457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/11/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024] Open
Abstract
The spread of antimicrobial resistance (AMR) is a global challenge. Close and continuous surveillance for quick detection of AMR can be difficult, especially in remote places. This narrative review focuses on the contributions of pharmacovigilance (PV) as an auxiliary tool for identifying and monitoring the ineffectiveness, resistance, and inappropriate use of antibiotics (ABs). The terms "drug ineffective", "therapeutic failure", "drug resistance", "pathogen resistance", and "multidrug resistance" were found in PV databases and dictionaries, denoting ineffectiveness. These terms cover a range of problems that should be better investigated because they are useful in warning about possible causes of AMR. "Medication errors", especially those related to dose and indication, and "Off-label use" are highlighted in the literature, suggesting inappropriate use of ABs. Hence, the included studies show that the terms of interest related to AMR and use are not only present but frequent in PV surveillance programs. This review illustrates the feasibility of using PV as a complementary tool for antimicrobial stewardship activities, especially in scenarios where other resources are scarce.
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Affiliation(s)
- Valcieny Sandes
- Postgraduate Program in Pharmaceutical Sciences, School of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho-373, Rio de Janeiro 21941-170, RJ, Brazil;
- National Cancer Institute, Pr. da Cruz Vermelha-23, Rio de Janeiro 20230-130, RJ, Brazil
| | | | - Elisangela Costa Lima
- Postgraduate Program in Pharmaceutical Sciences, School of Pharmacy, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho-373, Rio de Janeiro 21941-170, RJ, Brazil;
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Rebholz D, Liebchen U, Paal M, Vogeser M, Starp J, Gräfe C, Brozat CI, Happich FL, Habler K, Scharf C. Can linezolid be validly measured in endotracheal aspiration in critically ill patients? A proof-of-concept trial. Intensive Care Med Exp 2024; 12:47. [PMID: 38717627 PMCID: PMC11078899 DOI: 10.1186/s40635-024-00630-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of anti-infectives such as linezolid is routinely performed in blood of intensive care unit (ICU) patients to optimize target attainment. However, the concentration at the site of infection is considered more important for a successful therapy. Until now, bronchoalveolar lavage (BAL) is the gold standard to measure intrapulmonary concentrations of anti-infective agents. However, it is an invasive method and unsuitable for regular TDM. The aim of this proof-of-concept study was to investigate whether it is possible to reliably determine the intrapulmonary concentration of linezolid from endotracheal aspiration (ENTA). METHODS Intubated ICU patients receiving 600 mg intravenous linezolid twice daily were examined in steady state. First, preliminary experiments were performed in six patients to investigate which patients are suitable for linezolid measurement in ENTA. In a second step, trough and peak linezolid concentrations of plasma and ENTA were determined in nine suitable patients. RESULTS Linezolid can validly be detected in ENTA with viscous texture and > 0.5 mL volume. The mean (SD) linezolid trough concentration was 2.02 (1.27) mg/L in plasma and 1.60 (1.36) mg/L in ENTA, resulting in a median lung penetration rate of 104%. The mean (SD) peak concentration in plasma and ENTA was 10.77 (5.93) and 4.74 (2.66) mg/L. CONCLUSIONS Linezolid can validly be determined in ENTA with an adequate texture and volume. The penetration rate is comparable to already published BAL concentrations. This method might offer a simple and non-invasive method for TDM at the site of infection "lung". Due to promising results of the feasibility study, comparison of ENTA and BAL in the same patient should be investigated in a further trial.
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Affiliation(s)
- Diana Rebholz
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Starp
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Caroline Gräfe
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Clara I Brozat
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Felix L Happich
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Katharina Habler
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany.
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Rodríguez-Báez AS, Jiménez-Meseguer M, Milán-Segovia RDC, Romano-Moreno S, Barcia E, Ortiz-Álvarez A, García-Díaz B, Medellín-Garibay SE. Comparison of pharmacokinetics software for therapeutic drug monitoring of piperacillin in patients with severe infections. Eur J Hosp Pharm 2024; 31:201-206. [PMID: 36126967 PMCID: PMC11042351 DOI: 10.1136/ejhpharm-2022-003367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/05/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the predictive performance of population pharmacokinetic models for piperacillin (PIP) available in the software MwPharm, TDMx and ID-ODs for initial dosing selection and therapeutic drug monitoring (TDM) purposes. METHODS This is a prospective observational study in adult patients with severe infections receiving PIP treatment. Plasma concentrations were quantified by ultra-high performance liquid chromatography coupled to tandem mass spectrometry. The differences between predicted and observed PIP concentrations were evaluated with Bland-Altman plots; additionally, the relative and absolute bias and precision of the models were determined. RESULTS A total of 145 PIP plasma concentrations from 42 patients were analysed. For population prediction, MwPharm showed the best predictive performance with a mean relative difference of 34.68% (95% CI -197% to 266%) and a root mean square error (RMSE) of 60.42 µg/mL; meanwhile TDMx and ID-ODs under-predicted PIP concentrations. For individual prediction, the TDMx model was found to be the most precise with a mean relative difference of 7.61% (95% CI -57.63 to 72.86%), and RMSE of 17.86 µg/mL. CONCLUSION Current software for TDM is a valuable tool, but it may also include different population pharmacokinetic models in patients with severe infections, and should be evaluated before performing a model-based TDM in clinical practice. Considering the heterogeneous characteristics of patients with severe infections, this study demonstrates the need for therapy personalisation for PIP to improve pharmacokinetic/pharmacodynamic target attainment.
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Affiliation(s)
| | | | | | - Silvia Romano-Moreno
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, San Luis Potosi, SLP, Mexico
| | - Emilia Barcia
- Facultad de Farmacia, Universidad Complutense de Madrid, Madrid, Comunidad de Madrid, Spain
| | | | - Benito García-Díaz
- Servicio de Farmacia, Hospital Universitario Severo Ochoa, Leganés, Spain
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Booke H, Friedrichson B, Draheim L, von Groote TC, Frey O, Röhr A, Zacharowski K, Adam EH. No Sequestration of Commonly Used Anti-Infectives in the Extracorporeal Membrane Oxygenation (ECMO) Circuit-An Ex Vivo Study. Antibiotics (Basel) 2024; 13:373. [PMID: 38667049 PMCID: PMC11047533 DOI: 10.3390/antibiotics13040373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/12/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
Patients undergoing extracorporeal membrane oxygenation (ECMO) often require therapy with anti-infective drugs. The pharmacokinetics of these drugs may be altered during ECMO treatment due to pathophysiological changes in the drug metabolism of the critically ill and/or the ECMO therapy itself. This study investigates the latter aspect for commonly used anti-infective drugs in an ex vivo setting. A fully functional ECMO device circulated an albumin-electrolyte solution through the ECMO tubes and oxygenator. The antibiotic agents cefazolin, cefuroxim, cefepime, cefiderocol, linezolid and daptomycin and the antifungal agent anidulafungin were added. Blood samples were taken over a period of four hours and drug concentrations were measured via high-pressure liquid chromatography (HPLC) with UV detection. Subsequently, the study analyzed the time course of anti-infective concentrations. The results showed no significant changes in the concentration of any tested anti-infectives throughout the study period. This ex vivo study demonstrates that the ECMO device itself has no impact on the concentration of commonly used anti-infectives. These findings suggest that ECMO therapy does not contribute to alterations in the concentrations of anti-infective medications in severely ill patients.
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Affiliation(s)
- Hendrik Booke
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Albert-Schweitzer-Straße 33, 48149 Muenster, Germany
| | - Benjamin Friedrichson
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany; (B.F.); (L.D.); (K.Z.); (E.H.A.)
| | - Lena Draheim
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany; (B.F.); (L.D.); (K.Z.); (E.H.A.)
| | - Thilo Caspar von Groote
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, University of Muenster, Albert-Schweitzer-Straße 33, 48149 Muenster, Germany
| | - Otto Frey
- Department of Pharmacy, Heidenheim General Hospital, Schloßhaustraße 100, 89522 Heidenheim, Germany; (O.F.); (A.R.)
| | - Anka Röhr
- Department of Pharmacy, Heidenheim General Hospital, Schloßhaustraße 100, 89522 Heidenheim, Germany; (O.F.); (A.R.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany; (B.F.); (L.D.); (K.Z.); (E.H.A.)
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany; (B.F.); (L.D.); (K.Z.); (E.H.A.)
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El-Haffaf I, Marsot A, Hachemi D, Pesout T, Williams V, Smith MA, Albert M, Williamson D. Exposure levels and target attainment of piperacillin/tazobactam in adult patients admitted to the intensive care unit: a prospective observational study. Can J Anaesth 2024; 71:511-522. [PMID: 38243099 DOI: 10.1007/s12630-023-02689-8] [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: 03/13/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 01/21/2024] Open
Abstract
PURPOSE The objective of this study was to evaluate the exposure and the pharmacodynamic target attainment of piperacillin/tazobactam (PTZ) in adult critically ill patients. METHODS We conducted a prospective observational study in the intensive care unit (ICU) of the Hôpital du Sacré-Cœur de Montréal (a Level I trauma centre in Montreal, QC, Canada) between January 2021 and June 2022. We included patients aged 18 yr or older admitted to the ICU who received PTZ by intravenous administration. Demographic and clinical characteristics were collected, and clinical scores were calculated. On study day 1 of antimicrobial therapy, three blood samples were collected at the following timepoints: one hour after PTZ dose administration and at the middle and at the end of the dosing interval. The sampling schedule was repeated on days 4 and 7 of therapy if possible. Samples were analyzed by ultra-high performance liquid chromatography with diode array detector to determine the total piperacillin concentration. Middle- and end-of-interval concentrations were used for target attainment analyses, and were defined as a concentration above the minimal inhibitory concentration of 16 mg·L-1, corresponding to the breakpoint of Enterobacteriaceae and Pseudomonas aeruginosa. RESULTS Forty-three patients were recruited and 202 blood samples were analyzed. The most prevalent dose was 3/0.375 g every six hours (n = 50/73 doses administered, 68%) with a 30-min infusion. We observed marked variability over the three sampling timepoints, and the median [interquartile range] piperacillin concentrations at peak, middle of interval, and end of interval were 109.4 [74.0-152.3], 59.3 [21.1-74.4], and 25.3 [6.8-44.6] mg·L-1, respectively. When assessing target attainment, 37% of patients did not reach the efficacy target of a trough concentration of 16 mg·L-1. The majority of patients who were underexposed were patients with normal to augmented renal clearance. CONCLUSION In this prospective observational study of adult ICU patients receiving intravenous PTZ, a large proportion had subtherapeutic concentrations of piperacillin. This was most notable in patients with normal to augmented renal clearance. More aggressive dosage regimens may be required for this subpopulation to ensure attainment of efficacy targets.
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Affiliation(s)
- Ibrahim El-Haffaf
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada.
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de Polytechnique, Montreal, QC, H3T 1J4, Canada.
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Centre de recherche, CHU Sainte-Justine, Montréal, QC, Canada
| | - Djamila Hachemi
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Thomas Pesout
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Virginie Williams
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Marc-André Smith
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
| | - Martin Albert
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - David Williamson
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- CIUSSS-NIM-Hôpital du Sacré-Cœur de Montréal and CIUSSS-NIM Research Center, Montreal, QC, Canada
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McIntire C, Luna Torres J, Tang P, Vinks AA, Kaplan J, Tang Girdwood S. Piperacillin pharmacokinetics and pharmacodynamics in paediatric patients who received high frequency intra-operative piperacillin/tazobactam dosing. Int J Antimicrob Agents 2024; 63:107079. [PMID: 38161045 PMCID: PMC10923153 DOI: 10.1016/j.ijantimicag.2023.107079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/10/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
Piperacillin/tazobactam (PTZ) is a broad-spectrum antibiotic, typically dosed every six hours (q6h). Guidelines recommend dosing PTZ every 2 hours (q2h) intra-operatively for complex abdominal surgery, including liver transplant. The data supporting the guidelines for intra-operative dosing are sparse and the pharmacokinetics/pharmacodynamics (PK/PD) of q2h dosing has not been studied by simulation or in humans. In this study, PK/PD parameters of high-frequency intra-operative dosing and q6h post-operative dosing were compared in critically ill children. Paediatric patients who received PTZ during complex abdominal surgery or transplant and who had intra-operative and post-operative opportunistic samples were included. Using a published PK model and observed concentrations, individual piperacillin PK/PD parameters were estimated using Bayesian estimation. Alternative post-operative dosing strategies were simulated using the patients with the highest and lowest estimated piperacillin clearance. Thirteen patients were included (median age: 3.1 years, 85% liver transplant recipients). PK parameters in the intra-operative and post-operative phases were not significantly different (clearance: 15.8 ± 7.2 vs. 12.6 ± 6.3 L/h/70 kg, P=0.070; central volume: 13.4 [13.1, 13.8] vs. 15.2 [12.2, 16.0] L/70 kg, P=0.22). At an individual level, intra-operative clearance values were -35% to 139% of the post-operative values, whereas central volume intra-operative values were -40% to 77% of the post-operative values. Intra-operative piperacillin exposure was higher during high-frequency dosing compared with the post-operative period (AUC/h: 109 [93.4, 127] vs. 62.8 [41.6, 78.3] mg/L, P=0.002). Simulations showed great variation in optimal dosing strategies that would minimise toxicity and maximise efficacy, indicating a role for individualised dosing in paediatric surgical populations.
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Affiliation(s)
- Carter McIntire
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America
| | - Julie Luna Torres
- Office of Medical Education, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America
| | - Peter Tang
- Division of Pathology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America; Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America
| | - Alexander A Vinks
- Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America
| | - Jennifer Kaplan
- Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America
| | - Sonya Tang Girdwood
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America; Department of Paediatrics, University of Cincinnati College of Medicine, 3230 Eden Avenue, Cincinnati, OH, 45229, United States of America; Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, United States of America.
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Alsultan A, Dasuqi SA, Almohaizeie A, Aljutayli A, Aljamaan F, Omran RA, Alolayan A, Hamad MA, Alotaibi H, Altamimi S, Alghanem SS. External Validation of Obese/Critically Ill Vancomycin Population Pharmacokinetic Models in Critically Ill Patients Who Are Obese. J Clin Pharmacol 2024; 64:353-361. [PMID: 37862131 DOI: 10.1002/jcph.2375] [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: 07/27/2023] [Accepted: 10/17/2023] [Indexed: 10/22/2023]
Abstract
Obesity combined with critical illness might increase the risk of acquiring infections and hence mortality. In this patient population the pharmacokinetics of antimicrobials vary significantly, making antimicrobial dosing challenging. The objective of this study was to assess the predictive performance of published population pharmacokinetic models of vancomycin in patients who are critically ill or obese for a cohort of critically ill patients who are obese. This was a multi-center retrospective study conducted at 2 hospitals. Adult patients with a body mass index of ≥30 kg/m2 were included. PubMed was searched for published population pharmacokinetic studies in patients who were critically ill or obese. External validation was performed using Monolix software. A total of 4 models were identified in patients who were obese and 5 models were identified in patients who were critically ill. In total, 138 patients who were critically ill and obese were included, and the most accurate models for these patients were the Goti and Roberts models. In our analysis, models in patients who were critically ill outperformed models in patients who were obese. When looking at the most accurate models, both the Goti and the Roberts models had patient characteristics similar to ours in terms of age and creatinine clearance. This indicates that when selecting the proper model to apply in practice, it is important to account for all relevant variables, besides obesity.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Shereen A Dasuqi
- Department of Pharmacy, King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almohaizeie
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah Aljutayli
- Department of Pharmaceutics, Faculty of Pharmacy, Qassim University, Riyadh, Saudi Arabia
| | - Fadi Aljamaan
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Critical Care Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Rasha A Omran
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy, University of Jordan, Amman, Jordan
| | - Abdulaziz Alolayan
- Pharmacy Department, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
| | - Mohammed A Hamad
- Critical Care Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
- Department of Acute Medicine, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, UK
| | - Haifa Alotaibi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sarah Altamimi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sarah S Alghanem
- Department of Pharmacy Practice, College of Pharmacy at Kuwait University, Safat, Kuwait
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Milaković D, Kovačević T, Kovačević P, Barišić V, Avram S, Dragić S, Zlojutro B, Momčičević D, Miljković B, Vučićević K. Population Pharmacokinetic Model of Linezolid and Probability of Target Attainment in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome on Veno-Venous Extracorporeal Membrane Oxygenation-A Step toward Correct Dosing. Pharmaceutics 2024; 16:253. [PMID: 38399307 PMCID: PMC10892643 DOI: 10.3390/pharmaceutics16020253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/25/2024] Open
Abstract
During veno-venous extracorporeal membrane oxygenation (vv ECMO) therapy, antimicrobial drugs are frequently used, and appropriate dosing is challenging due to there being limited data to support the dosage. Linezolid is effective against multidrug-resistant Gram-positive pathogens frequently isolated in ECMO patients. In total, 53 steady-state linezolid levels were obtained following 600 mg intravenous (IV) injections every 8 h, and these were used to develop a population pharmacokinetic (PopPK) model in patients with COVID-19-associated acute respiratory distress syndrome (CARDS) on vv ECMO. The data were analyzed using a nonlinear mixed-effects modelling approach. Monte Carlo simulation generated 5000 patients' individual PK parameters and corresponding concentration-time profiles using the PopPK model, following the administration of 600 mg/8 h (a higher-than-standard dosing) and 600 mg/12 h (standard). The probabilities of pharmacokinetic/pharmacodynamic (PK/PD) target attainment (PTA) and the cumulative fraction of responses (CFR) for three pathogens were calculated and compared between the two dosing scenarios. Linezolid 600 mg/8 h was predicted to achieve greater than or equal to 85%Tf>MIC in at least 90% of the patients with CARDS on vv ECMO compared to only approximately two thirds of the patients after dosing every 12 h at a minimal inhibitory concentration (MIC) of 2 mg/L. In addition, for the same MIC, fAUC24/MIC ≥ 80 was achieved in almost three times the number of patients following an 8-h versus a 12-h interval. PopPK simulation predicted that a significantly higher proportion of the patients with CARDS on vv ECMO would achieve the PK/PD targets following the 8-h dosing interval compared to standard linezolid dosing. Nevertheless, the safety concern, in particular, for thrombocytopenia, with higher-than-standard linezolid dosage is reasonable, and consequently, monitoring is essential.
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Affiliation(s)
- Dragana Milaković
- Department of Nuclear Medicine and Thyroid Gland Diseases, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
| | - Tijana Kovačević
- Pharmacy Department, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina; (P.K.)
| | - Pedja Kovačević
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina; (P.K.)
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
| | - Vedrana Barišić
- Pharmacy Department, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
| | - Sanja Avram
- Institute of Laboratory Diagnostic, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
| | - Saša Dragić
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina; (P.K.)
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
| | - Biljana Zlojutro
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina; (P.K.)
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
| | - Danica Momčičević
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Bosnia and Herzegovina; (P.K.)
- Medical Intensive Care Unit, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Bosnia and Herzegovina
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade-Faculty of Pharmacy, 11221 Belgrade, Serbia
| | - Katarina Vučićević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade-Faculty of Pharmacy, 11221 Belgrade, Serbia
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Kamidani R, Okada H, Kawasaki Y, Shimada T, Tamaoki Y, Nakashima Y, Nishio A, Fukuda H, Minamiyama T, Yoshida T, Yoshimura G, Miura T, Ishihara T, Fukuta T, Kitagawa Y, Suzuki K, Miyake T, Doi T, Yoshida T, Tetsuka N, Yoshida S, Ogura S. Impact of augmented renal clearance on anticoagulant therapy in critically ill patients with coronavirus disease 2019: A retrospective cohort study. J Infect Chemother 2024; 30:111-117. [PMID: 37717607 DOI: 10.1016/j.jiac.2023.09.017] [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: 06/18/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION This study aimed to determine the impact of augmented renal clearance (ARC) on anticoagulation therapy in critically ill patients with coronavirus disease 2019 (COVID-19). METHODS This retrospective cohort study included adult patients with severe COVID-19 with ARC who had been treated at our hospital between 2020 and 2021. We measured the estimated glomerular filtration rate calculated by the Chronic Kidney Disease Epidemiology Collaboration formula (eGFRCKD-EPI) every morning, and ARC condition was defined as eGFRCKD-EPI ≥ 130 mL/min/1.73 m2. Multivariate regression analysis with Huber-White sandwich estimator was performed to examine the association of unfractionated heparin (UH) dosage between blood test timings with activated partial thromboplastin time (APTT) compared with and without ARC. RESULTS We identified 38 enrolled patients: seven and 31 in the ARC and non-ARC groups, respectively. In the ARC coexisting condition, a higher dose of UH, which corresponded to the total dose in 24 h from the previous day, was required to achieve the same APTT prolongation, with a significant difference (p < 0.001). CONCLUSIONS Our study suggests that careful monitoring and consideration of higher UH doses in critically ill patients with COVID-19 is necessary because anticoagulation failure can occur during ARC.
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Affiliation(s)
- Ryo Kamidani
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan; Abuse Prevention Center, Gifu University Graduate School of Medicine, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Hideshi Okada
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan; Center for One Medicine Innovative Translational Research, Gifu University Institute for Advanced Study, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Yuki Kawasaki
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Takuto Shimada
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Yuto Tamaoki
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Yusuke Nakashima
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Ayane Nishio
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Hirotsugu Fukuda
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Toru Minamiyama
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Tomoki Yoshida
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Genki Yoshimura
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Tomotaka Miura
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan; Department of Infection Control, Gifu University Graduate School of Medicine, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Tetsuya Fukuta
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Yuichiro Kitagawa
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Kodai Suzuki
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Takahito Miyake
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Tomoaki Doi
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Takahiro Yoshida
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Nobuyuki Tetsuka
- Department of Infection Control, Gifu University Graduate School of Medicine, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Shozo Yoshida
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan; Abuse Prevention Center, Gifu University Graduate School of Medicine, Yanagido 1-1, Gifu City, Gifu, Japan.
| | - Shinji Ogura
- Advanced Critical Care Center, Gifu University Hospital, Yanagido 1-1, Gifu City, Gifu, Japan.
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Wulkersdorfer B, Bergmann F, Amann L, Fochtmann-Frana A, Al Jalali V, Kurdina E, Lackner E, Wicha SG, Dorn C, Schäfer B, Ihra G, Rath T, Radtke C, Zeitlinger M. Effect of albumin substitution on pharmacokinetics of piperacillin/tazobactam in patients with severe burn injury admitted to the ICU. J Antimicrob Chemother 2024; 79:262-270. [PMID: 38069908 PMCID: PMC10832600 DOI: 10.1093/jac/dkad368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/18/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Pathophysiological changes in severely burned patients alter the pharmacokinetics (PK) of anti-infective agents, potentially leading to subtherapeutic concentrations at the target site. Albumin supplementation, to support fluid resuscitation, may affect pharmacokinetic properties by binding drugs. This study aimed to investigate the PK of piperacillin/tazobactam in burn patients admitted to the ICU before and after albumin substitution as total and unbound concentrations in plasma. PATIENTS AND METHODS Patients admitted to the ICU and scheduled for 4.5 g piperacillin/tazobactam administration and 200 mL of 20% albumin substitution as part of clinical routine were included. Patients underwent IV microdialysis, and simultaneous arterial plasma sampling, at baseline and multiple timepoints after drug administration. PK analysis of total and unbound drug concentrations under steady-state conditions was performed before and after albumin supplementation. RESULTS A total of seven patients with second- to third-degree burns involving 20%-60% of the total body surface were enrolled. Mean (SD) AUC0-8 (h·mg/L) of total piperacillin/tazobactam before and after albumin substitution were 402.1 (242)/53.2 (27) and 521.8 (363)/59.7 (32), respectively. Unbound mean AUC0-8 before and after albumin supplementation were 398.9 (204)/54.5 (25) and 456.4 (439)/64.5 (82), respectively. CONCLUSIONS Albumin supplementation had little impact on the PK of piperacillin/tazobactam. After albumin supplementation, there was a numerical increase in mean AUC0-8 of total and unbound piperacillin/tazobactam, whereas similar Cmax values were observed. Future studies may investigate the effect of albumin supplementation on drugs with a higher plasma protein binding.
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Affiliation(s)
- Beatrix Wulkersdorfer
- Medical University of Vienna, Department of Clinical Pharmacology, Währinger Gürtel 18-20, 1090 Vienna, Austria
- Orthopedic Clinic—SKA Zicksee, Otto-Pohanka-Platz 1, 7161 St.Andrä am Zicksee, Austria
| | - Felix Bergmann
- Medical University of Vienna, Department of Clinical Pharmacology, Währinger Gürtel 18-20, 1090 Vienna, Austria
- Medical University of Vienna, Department of Plastic, Reconstructive, and Aesthetic Surgery, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Lisa Amann
- University of Hamburg, Department of Clinical Pharmacology, Institute of Pharmacy, Bundesstrasse 45, 20146 Hamburg, Germany
| | - Alexandra Fochtmann-Frana
- Medical University of Vienna, Department of Plastic, Reconstructive, and Aesthetic Surgery, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Valentin Al Jalali
- Medical University of Vienna, Department of Clinical Pharmacology, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Elizaveta Kurdina
- Medical University of Vienna, Department of Clinical Pharmacology, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Edith Lackner
- Medical University of Vienna, Department of Clinical Pharmacology, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Sebastian G Wicha
- University of Hamburg, Department of Clinical Pharmacology, Institute of Pharmacy, Bundesstrasse 45, 20146 Hamburg, Germany
| | - Christoph Dorn
- University of Regensburg, Institute of Pharmacy, Universitätsstraße 31, 93053 Regensburg, Germany
| | - Bruno Schäfer
- Medical University of Vienna, Department of Anesthesiology and General Intensive Care, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Gerald Ihra
- Medical University of Vienna, Department of Anesthesiology and General Intensive Care, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Thomas Rath
- Medical University of Vienna, Department of Plastic, Reconstructive, and Aesthetic Surgery, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Christine Radtke
- Medical University of Vienna, Department of Plastic, Reconstructive, and Aesthetic Surgery, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Markus Zeitlinger
- Medical University of Vienna, Department of Clinical Pharmacology, Währinger Gürtel 18-20, 1090 Vienna, Austria
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El-Haffaf I, Laverdière J, Albert M, Marsot A, Williamson D. Potential benefits of therapeutic drug monitoring for beta-lactam antibiotics in augmented renal clearance patients: a case report. Can J Physiol Pharmacol 2024; 102:69-74. [PMID: 37713726 DOI: 10.1139/cjpp-2023-0109] [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] [Indexed: 09/17/2023]
Abstract
Augmented renal clearance (ARC) is commonly described in critically ill patients, making drug pharmacokinetics even harder to predict in this population. This case report displays the value of therapeutic drug monitoring (TDM) of piperacillin/tazobactam (PTZ) in this population. We identified two patients with ARC and intermittent administration of PTZ who took part in a prospective, descriptive study conducted at Hôpital du Sacré-Cœur de Montréal. Both had plasma samples drawn at peak, middle, and end of their dosing intervals of PTZ. Minimal inhibitory concentrations (MICs) of 4 and 8 mg/L were chosen to evaluate therapeutic target attainment at middle and end of dosing interval. The first patient was a 52-year-old male with a renal clearance rate estimated at 147 mL/min who received 3.375 g PTZ every 6 h. The second patient, a 49-year-old male, had an estimated renal clearance rate of 163 mL/min and received the same regimen. Both patients had piperacillin concentrations above the target MICs at middle of the dosing interval, but they failed to reach a trough concentration above 8 mg/L. The present case report showcases two patients with subtherapeutic PTZ concentrations despite strict following of local administration protocols. This suboptimal administration could not only lead to treatment failure, but also to the selection and growth of resistant pathogens. Implementing TDM would offer the possibility to adjust drug regimens in real-time and prevent situations like these from occurring.
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Affiliation(s)
- Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Jean Laverdière
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Martin Albert
- Hôpital du Sacré-Cœur de Montréal, CIUSSS NIM Research Center, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Centre de recherche, CHU Sainte-Justine, Montréal, QC, Canada
| | - David Williamson
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Hôpital du Sacré-Cœur de Montréal, CIUSSS NIM Research Center, Montreal, QC, Canada
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Viertel K, Feles E, Schulte M, Annecke T, Mattner F. Serum concentration of continuously administered vancomycin influences efficacy and safety in critically ill adults: a systematic review. Int J Antimicrob Agents 2023; 62:107005. [PMID: 37839714 DOI: 10.1016/j.ijantimicag.2023.107005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/12/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVES Vancomycin is used to treat Gram-positive infections in critically ill adults. For vancomycin administered by continuous infusion (CI), various target ranges have been used, ranging from 15-20 mg/L to 30-40 mg/L. This systematic literature review was conducted to investigate the impact of steady-state serum concentration (Css) of CI on safety and efficacy of therapy in critically ill adults. METHODS Relevant literature was identified by searching two electronic databases (PubMed, Cochrane Library) and Google Scholar from inception until July 2023, focusing on studies reporting measured Css and treatment outcomes (e.g. mortality, nephrotoxicity) with CI. Due to study heterogeneity, a narrative synthesis of the evidence was performed. RESULTS Twenty-one publications were included with a total of 2949 patients. Mortality was higher (two studies, n = 388 patients) and clinical cure was lower (one study, n = 40 patients) with Css < 15 mg/L measured 24 h after initiation of CI (C24). An adequate loading dose appeared most important for maintaining higher C24. Generally, higher Css was associated with higher rates of acute kidney injury (AKI) (15 studies, n = 2331 patients). It was calculated that Css < 25 mg/L (versus ≥25 mg/L) was preferable for reducing nephrotoxicity (three studies, n = 515 patients). CONCLUSIONS Despite sparse data availability, the target range of 15-25 mg/L in CI may increase clinical cure and reduce mortality and AKI. In future research, vancomycin Css cohorts should be formed to allow evaluation of the impact of Css of CI on treatment outcomes.
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Affiliation(s)
- Katrin Viertel
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany.
| | - Elisabeth Feles
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
| | - Melanie Schulte
- Central Pharmacy, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Thorsten Annecke
- Department of Anaesthesiology and Intensive Care Medicine, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Frauke Mattner
- Institute of Hygiene, Cologne Merheim Medical Centre, University Hospital of Witten/Herdecke, Ostmerheimer Str. 200, 51109 Cologne, Germany; Division of Hygiene and Environmental Medicine, Department of Human Medicine, Faculty of Health, Witten/Herdecke University, Witten, Alfred-Herrhausen-Straße 50, 58455 Witten, Germany
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Cervantes FC, Mizuno T, Dong M, Tang P, Arbough T, Vinks AA, Kaplan JM, Girdwood SCT. Ceftriaxone Pharmacokinetics and Pharmacodynamics in 2 Pediatric Patients on Extracorporeal Membrane Oxygenation Therapy. Ther Drug Monit 2023; 45:832-836. [PMID: 37725684 PMCID: PMC10840633 DOI: 10.1097/ftd.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/13/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Critically ill patients with cardiac or respiratory failure may require extracorporeal membrane oxygenation (ECMO). Antibiotics are frequently administered when the suspected cause of organ failure is an infection. Ceftriaxone, a β-lactam antibiotic, is commonly used in patients who are critically ill. Although studies in adults on ECMO have suggested minimal impact on ceftriaxone pharmacokinetics, limited research exists on ceftriaxone pharmacokinetics/pharmacodynamics (PK/PD) in pediatric ECMO patients. We report the PK profiles and target attainment of 2 pediatric patients on ECMO who received ceftriaxone. METHODS Ceftriaxone concentrations were measured in 2 pediatric patients on ECMO using scavenged opportunistic sampling. PK profiles were generated and individual PK parameters were estimated using measured free ceftriaxone concentrations and a published population PK model in children who are critically ill, using Bayesian estimation. RESULTS Patient 1, an 11-year-old boy on venovenous ECMO for respiratory failure received 2 doses of 52 mg/kg ceftriaxone 12 hours apart while on ECMO and additional doses every 12 hours off ECMO. On ECMO, ceftriaxone clearance was 13.0 L/h/70 kg compared with 7.6 L/h/70 kg off ECMO, whereas the model-predicted mean clearance in children who are critically ill without ECMO support was 6.54 L/h/70 kg. Patient 2, a 2-year-old boy on venoarterial ECMO due to cardiac arrest received 50 mg/kg ceftriaxone every 12 hours while on ECMO for >7 days. Only clearance while on ECMO could be estimated (9.1 L/h/70 kg). Trough concentrations in both patients were >1 mg/L (the breakpoint for Streptococcus pneumoniae ) while on ECMO. CONCLUSIONS ECMO increased ceftriaxone clearance above the model-predicted clearances in the 2 pediatric patients studied. Twelve-hour dosing allowed concentrations to remain above the breakpoint for commonly targeted bacteria but not 4 times the breakpoint in one patient, suggesting that precision dosing may be beneficial to ensure target attainment in children on ECMO.
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Affiliation(s)
- Francisco C. Cervantes
- Department of Medical Education, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
| | - Tomoyuki Mizuno
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Min Dong
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Peter Tang
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Trent Arbough
- Department of Medical Education, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
| | - Alexander A. Vinks
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Jennifer M. Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
| | - Sonya C. Tang Girdwood
- Department of Pediatrics, University of Cincinnati College of Medicine, 320 Eden Avenue, Cincinnati, OH, 45267, United States of America
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45220, United States of America
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Chai MG, Roberts JA, Kelly CF, Ungerer JPJ, McWhinney BC, Lipman J, Farkas A, Cotta MO. Efficiency of dosing software using Bayesian forecasting in achieving target antibiotic exposures in critically ill patients, a prospective cohort study. Anaesth Crit Care Pain Med 2023; 42:101296. [PMID: 37579945 DOI: 10.1016/j.accpm.2023.101296] [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: 04/27/2023] [Revised: 06/28/2023] [Accepted: 08/06/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Broad-spectrum antibiotics such as beta-lactams and vancomycin are frequently used to treat critically ill patients, however, a significant number do not achieve target exposures. Therapeutic drug monitoring (TDM) combined with Bayesian forecasting dosing software may improve target attainment in these patients. This study aims to describe the efficiency of dosing software for achieving target exposures of selected beta-lactam antibiotics and vancomycin in critically ill patients. METHODS A prospective cohort study was undertaken in an adult intensive care unit (ICU). Patients prescribed vancomycin, piperacillin-tazobactam and meropenem were included if they exhibited a subtherapeutic or supratherapeutic exposure informed by TDM. The dosing software, ID-ODS™, was used to generate dosing recommendations which could be either accepted or rejected by the treating team. Repeat antibiotic TDM were requested to determine if target exposures were achieved. RESULTS Between March 2020 and December 2021, 70 were included in the analysis. Software recommendations were accepted for 56 patients (80%) with 50 having repeated antibiotic measurements. Forty-three of the 50 patients (86%) achieved target exposures after one software recommendation, with 3 of the remaining 7 patients achieving target exposures after 2. Forty-seven patients out of the 50 patients (94%) achieved the secondary outcome of clinical cure. There were no antibiotic exposure-related adverse events reported. CONCLUSION The use of TDM combined with Bayesian forecasting dosing software increases the efficiency for achieving target antibiotic exposures in the ICU. Clinical trials comparing this approach with other dosing strategies are required to further validate these findings.
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Affiliation(s)
- Ming G Chai
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | - Jason A Roberts
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, University of Montpellier, Nimes, France; Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Christina F Kelly
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jacobus P J Ungerer
- Pathology Queensland, Brisbane, Australia; Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | | | - Jeffrey Lipman
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD, Australia
| | - Andras Farkas
- Optimum Dosing Strategies, Bloomingdale, NJ, United States
| | - Menino O Cotta
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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48
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Fresán D, Luque S, Benítez-Cano A, Sorlí L, Montero MM, De-Antonio M, Vega V, Roberts JA, Horcajada JP, Grau S. Real-world experience of therapeutic drug monitoring and PK/PD achievement of ceftaroline administered by different infusion regimens in patients with confirmed infections caused by Gram-positive bacteria. J Antimicrob Chemother 2023; 78:2810-2815. [PMID: 37823445 DOI: 10.1093/jac/dkad296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/14/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Ceftaroline is a novel cephalosporin active against MDR Gram-positive (GP) bacteria. For β-lactam antibiotics, such as ceftaroline, prolonged infusions and therapeutic drug monitoring (TDM) are used for dosage optimization based on their pharmacokinetics/pharmacodynamics (PK/PD). OBJECTIVES To describe our experience with TDM and PK/PD target attainment of ceftaroline administered by intermittent and prolonged infusion in a cohort of patients with MDR-GP bacterial infections. METHODS Patients treated with ceftaroline administered by continuous (24 h), extended (3 h/6 h) and intermittent infusion (1 h) and undergoing TDM of plasma concentrations were included. A 100%fT>4×MIC was the pre-specified PK/PD target and 100%fT>10×MIC was considered overexposure. Dose recommendations were made based on TDM results and each patient's clinical condition. RESULTS Twelve patients [83.3% male, median age of 73 (38-83) years] were included. Nine patients (75%) achieved 100%fT>4×MIC, all under prolonged infusions. In one patient, the 100%fT was >10×MIC but no toxicity was observed. Based on TDM results, initial doses were recommended to be maintained in eight patients, decreased in three and increased in one. CONCLUSIONS The administration of ceftaroline by prolonged infusion together with TDM may be a useful strategy for achieving the desired PK/PD target in these patients. However, more studies evaluating the relationship between PK/PD attainment and clinical outcomes are needed.
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Affiliation(s)
- Daniel Fresán
- Pharmacy Department, Hospital Universitario de Navarra, Pamplona, Spain
| | - Sonia Luque
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
| | - Adela Benítez-Cano
- Department of Anaesthesiology and Surgical Intensive Care, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Luisa Sorlí
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - María Milagro Montero
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - Marta De-Antonio
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Victoria Vega
- Analytical Department, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Juan P Horcajada
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Infectious Diseases Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBERINFEC, ISCIII-CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Av. de Monforte de Lemos, 5, Madrid 28029, Spain
- Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra, Barcelona, Spain
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Dubinsky SDJ, Watt KM, Imburgia CE, Mcknite AM, Hunt JP, Rice C, Rower JE, Edginton AN. Anakinra Removal by Continuous Renal Replacement Therapy: An Ex Vivo Analysis. Crit Care Explor 2023; 5:e1010. [PMID: 38107537 PMCID: PMC10723863 DOI: 10.1097/cce.0000000000001010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES Patients with sepsis are at significant risk for multiple organ dysfunction, including the lungs and kidneys. To manage the morbidity associated with kidney impairment, continuous renal replacement therapy (CRRT) may be required. The extent of anakinra pharmacokinetics in CRRT remains unknown. The objectives of this study were to investigate the anakinra-circuit interaction and quantify the rate of removal from plasma. DESIGN The anakinra-circuit interaction was evaluated using a closed-loop ex vivo CRRT circuit. CRRT was performed in three phases based on the method of solute removal: 1) hemofiltration, 2) hemodialysis, and 3) hemodiafiltration. Standard control samples of anakinra were included to assess drug degradation. SETTING University research laboratory. PATIENTS None. INTERVENTIONS Anakinra was administered to the CRRT circuit and serial prefilter blood samples were collected along with time-matched control and hemofiltrate samples. Each circuit was run in triplicate to assess inter-run variability. Concentrations of anakinra in each reference fluid were measured by enzyme-linked immunosorbent assay. Transmembrane filter clearance was estimated by the product of the sieving coefficient/dialysate saturation constant and circuit flow rates. MEASUREMENTS AND MAIN RESULTS Removal of anakinra from plasma occurred within minutes for each CRRT modality. Average drug remaining (%) in plasma following anakinra administration was lowest with hemodiafiltration (34.9%). The average sieving coefficient was 0.34, 0.37, and 0.41 for hemodiafiltration, hemofiltration, and hemodialysis, respectively. Transmembrane clearance was fairly consistent across each modality with the highest during hemodialysis (5.53 mL/min), followed by hemodiafiltration (4.99 mL/min), and hemofiltration (3.94 mL/min). Percent drug remaining within the control samples (93.1%) remained consistent across each experiment, indicating negligible degradation within the blood. CONCLUSIONS The results of this analysis are the first to demonstrate that large molecule therapeutic proteins such as anakinra, are removed from plasma with modern CRRT technology. Current dosing recommendations for patients with severe renal impairment may result in subtherapeutic anakinra concentrations in those receiving CRRT.
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Affiliation(s)
- Samuel D J Dubinsky
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
| | - Kevin M Watt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - Carina E Imburgia
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Autumn M Mcknite
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, UT
| | - J Porter Hunt
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT
| | - Cassandra Rice
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, Center for Human Toxicology, University of Utah, Salt Lake City, UT
| | - Andrea N Edginton
- University of Waterloo, School of Pharmacy, Faculty of Science, Waterloo, ON, Canada
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50
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Wieringa A, Ewoldt TMJ, Gangapersad RN, Gijsen M, Parolya N, Kats CJAR, Spriet I, Endeman H, Haringman JJ, van Hest RM, Koch BCP, Abdulla A. Predicting Beta-Lactam Target Non-Attainment in ICU Patients at Treatment Initiation: Development and External Validation of Three Novel (Machine Learning) Models. Antibiotics (Basel) 2023; 12:1674. [PMID: 38136709 PMCID: PMC10740552 DOI: 10.3390/antibiotics12121674] [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: 10/31/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/24/2023] Open
Abstract
In the intensive care unit (ICU), infection-related mortality is high. Although adequate antibiotic treatment is essential in infections, beta-lactam target non-attainment occurs in up to 45% of ICU patients, which is associated with a lower likelihood of clinical success. To optimize antibiotic treatment, we aimed to develop beta-lactam target non-attainment prediction models in ICU patients. Patients from two multicenter studies were included, with intravenous intermittent beta-lactam antibiotics administered and blood samples drawn within 12-36 h after antibiotic initiation. Beta-lactam target non-attainment models were developed and validated using random forest (RF), logistic regression (LR), and naïve Bayes (NB) models from 376 patients. External validation was performed on 150 ICU patients. We assessed performance by measuring discrimination, calibration, and net benefit at the default threshold probability of 0.20. Age, sex, serum creatinine, and type of beta-lactam antibiotic were found to be predictive of beta-lactam target non-attainment. In the external validation, the RF, LR, and NB models confirmed good discrimination with an area under the curve of 0.79 [95% CI 0.72-0.86], 0.80 [95% CI 0.73-0.87], and 0.75 [95% CI 0.67-0.82], respectively, and net benefit in the RF and LR models. We developed prediction models for beta-lactam target non-attainment within 12-36 h after antibiotic initiation in ICU patients. These online-accessible models use readily available patient variables and help optimize antibiotic treatment. The RF and LR models showed the best performance among the three models tested.
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Affiliation(s)
- André Wieringa
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Clinical Pharmacy, Isala Hospital, Dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Tim M. J. Ewoldt
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Ravish N. Gangapersad
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (M.G.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
| | - Nestor Parolya
- Delft Institute of Applied Mathematics, Mekelweg 4, 2628 CD Delft, The Netherlands;
| | - Chantal J. A. R. Kats
- Department of Hospital Pharmacy, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, The Netherlands;
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (M.G.); (I.S.)
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium
| | - Henrik Endeman
- Department of Intensive Care, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Jasper J. Haringman
- Department of Intensive Care, Isala Hospital, Dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Reinier M. van Hest
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
| | - Birgit C. P. Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (T.M.J.E.); (R.N.G.); (B.C.P.K.); (A.A.)
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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