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Neef SK, Hinderer AD, Arbash W, Kinzig M, Sörgel F, Wunder C, Schwab M, Hofmann U. A high performance liquid chromatography-tandem mass spectrometry assay for therapeutic drug monitoring of 10 drug compounds commonly used for antimicrobial therapy in plasma and serum of critically ill patients: Method optimization, validation, cross-validation and clinical application. Clin Chim Acta 2024; 559:119690. [PMID: 38677452 DOI: 10.1016/j.cca.2024.119690] [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: 09/14/2023] [Revised: 03/14/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND AND AIMS Intensive care antibiotic treatment faces challenges due to substantial pharmacokinetic differences in critically ill patients. Individualized antibiotic dosing guided by therapeutic drug monitoring (TDM) is considered to minimize the risk of treatment failure and toxicity. This study aimed to develop a valid method for simultaneous LC-MS/MS quantification of 10 drugs frequently used in intensive care antibiotic therapy for which TDM-guided dosing is recommended: piperacillin, meropenem, flucloxacillin, cefuroxime, vancomycin, colistin A and B, linezolid, ciprofloxacin and tazobactam. METHODS AND RESULTS Thorough optimization of sample preparation and chromatography resulted in a fast and simple method based on protein precipitation of 50 µL plasma or serum and gradient elution using an Acquity UPLC HSS-T3 column. Electrospray ionization-triple quadrupole mass spectrometry in dynamic multiple reaction monitoring was used for quantification, covering the therapeutic range of each drug compound. Validation following EMA and FDA recommendations, including inter-platform validation and inter-laboratory comparison, demonstrated high accuracy, precision and robustness of the new method. The assay was successfully used to monitor plasma antibiotic levels of critically ill patients (n = 35). CONCLUSION The established multiplex method covers major drug classes with documented dosing challenges, provides a reliable basis for the implementation of high-throughput TDM, and its application confirmed the clinical impact of TDM in a real-world setting.
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Affiliation(s)
- Sylvia K Neef
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany and University of Tübingen, Tübingen, Germany
| | - Anna-Diana Hinderer
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany and University of Tübingen, Tübingen, Germany
| | - Wassim Arbash
- Department of Anesthesiolgy and Intensive Care Medicine, Robert-Bosch Hospital, Stuttgart, Germany
| | - Martina Kinzig
- IBMP - Institute for Biomedical and Pharmaceutical Research, Nürnberg-Heroldsberg, Germany
| | - Fritz Sörgel
- IBMP - Institute for Biomedical and Pharmaceutical Research, Nürnberg-Heroldsberg, Germany
| | - Christian Wunder
- Department of Anesthesiolgy and Intensive Care Medicine, Robert-Bosch Hospital, Stuttgart, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany and University of Tübingen, Tübingen, Germany; Departments of Clinical Pharmacology and of Pharmacy and Biochemistry, University Tübingen, Tübingen, Germany
| | - Ute Hofmann
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany and University of Tübingen, Tübingen, Germany.
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Geilen J, Kainz M, Zapletal B, Naka A, Tichy J, Jäger W, Böhmdorfer M, Zeitlinger M, Schultz MJ, Stamm T, Ritschl V, Geleff S, Tschernko E. Antimicrobial Drug Penetration Is Enhanced by Lung Tissue Inflammation and Injury. Am J Respir Crit Care Med 2024; 209:829-839. [PMID: 38099833 DOI: 10.1164/rccm.202306-0974oc] [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: 06/07/2023] [Accepted: 12/15/2023] [Indexed: 04/04/2024] Open
Abstract
Rationale: Pneumonia is a frequent and feared complication in intubated critically ill patients. Tissue concentrations of antimicrobial drugs need to be sufficiently high to treat the infection and also prevent development of bacterial resistance. It is uncertain whether pulmonary inflammation and injury affect antimicrobial drug penetration into lung tissue.Objectives: To determine and compare tissue and BAL fluid concentrations of ceftaroline fosamil and linezolid in a model of unilateral acute lung injury in pigs and to evaluate whether dose adjustment is necessary to reach sufficient antimicrobial concentrations in injured lung tissue.Methods: After induction of unilateral acute lung injury, ceftaroline fosamil and linezolid were administered intravenously. Drug concentrations were measured in lung tissue through microdialysis and in blood and BAL fluid samples during the following 8 hours. The primary endpoint was the tissue concentration area under the concentration curve in the first 8 hours (AUC0-8 h) of the two antimicrobial drugs.Measurements and Main Results: In 10 pigs, antimicrobial drug concentrations were higher in inflamed and injured lung tissue compared with those in uninflamed and uninjured lung tissue (median ceftaroline fosamil AUC0-8 h [and interquartile range] = 26.7 mg ⋅ h ⋅ L-1 [19.7-39.0] vs. 16.0 mg ⋅ h ⋅ L-1 [13.6-19.9], P = 0.02; median linezolid AUC0-8 h 76.0 mg ⋅ h ⋅ L-1 [68.1-96.0] vs. 54.6 mg ⋅ h ⋅ L-1 [42.7-60.9], P = 0.01), resulting in a longer time above the minimal inhibitory concentration and in higher peak concentrations and dialysate/plasma ratios. Penetration into BAL fluid was excellent for both antimicrobials, but without left-to-right differences (ceftaroline fosamil, P = 0.78; linezolid, P = 1.00).Conclusions: Tissue penetration of two commonly used antimicrobial drugs for pneumonia is enhanced by early lung tissue inflammation and injury, resulting in longer times above the minimal inhibitory concentration. Thus, lung tissue inflammation ameliorates antimicrobial drug penetration during the acute phase.
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Affiliation(s)
- Johannes Geilen
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Matthias Kainz
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Bernhard Zapletal
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Asami Naka
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Johanna Tichy
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
| | - Walter Jäger
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Michaela Böhmdorfer
- Department of Pharmaceutical Sciences, University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Clinical Pharmacokinetics/Pharmacogenetics, and Imaging
| | - Marcus J Schultz
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
- Department of Intensive Care, Amsterdam University Medical Centers, location "AMC", University of Amsterdam, Amsterdam, the Netherlands; and
| | - Tanja Stamm
- Institute of Outcomes Research, Center for Medical Data Science, and
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Valentin Ritschl
- Institute of Outcomes Research, Center for Medical Data Science, and
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Silvana Geleff
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Edda Tschernko
- Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, General Intensive Care, and Pain Management
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Hosmann A, Moser MM, van Os W, Gramms L, al Jalali V, Sanz Codina M, Plöchl W, Lier C, Kees F, Dorn C, Rössler K, Reinprecht A, Zeitlinger M. Linezolid brain penetration in neurointensive care patients. J Antimicrob Chemother 2024; 79:669-677. [PMID: 38323369 PMCID: PMC10904716 DOI: 10.1093/jac/dkae025] [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: 09/27/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Linezolid exposure in critically ill patients is associated with high inter-individual variability, potentially resulting in subtherapeutic antibiotic exposure. Linezolid exhibits good penetration into the CSF, but its penetration into cerebral interstitial fluid (ISF) is unknown. OBJECTIVES To determine linezolid penetration into CSF and cerebral ISF of neurointensive care patients. PATIENTS AND METHODS Five neurocritical care patients received 600 mg of linezolid IV twice daily for treatment of extracerebral infections. At steady state, blood and CSF samples were collected from arterial and ventricular catheters, and microdialysate was obtained from a cerebral intraparenchymal probe. RESULTS The median fAUC0-24 was 57.6 (24.9-365) mg·h/L in plasma, 64.1 (43.5-306.1) mg·h/L in CSF, and 27.0 (10.7-217.6) mg·h/L in cerebral ISF. The median penetration ratio (fAUCbrain_or_CSF/fAUCplasma) was 0.5 (0.25-0.81) for cerebral ISF and 0.92 (0.79-1) for CSF. Cerebral ISF concentrations correlated well with plasma (R = 0.93, P < 0.001) and CSF levels (R = 0.93, P < 0.001).The median fAUC0-24/MIC ratio was ≥100 in plasma and CSF for MICs of ≤0.5 mg/L, and in cerebral ISF for MICs of ≤0.25 mg/L. The median fT>MIC was ≥80% of the dosing interval in CSF for MICs of ≤0.5 mg/L, and in plasma and cerebral ISF for MICs of ≤0.25 mg/L. CONCLUSIONS Linezolid demonstrates a high degree of cerebral penetration, and brain concentrations correlate well with plasma and CSF levels. However, substantial variability in plasma levels, and thus cerebral concentrations, may result in subtherapeutic tissue concentrations in critically ill patients with standard dosing, necessitating therapeutic drug monitoring.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Miriam M Moser
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Wisse van Os
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Leon Gramms
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Valentin al Jalali
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Maria Sanz Codina
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Walter Plöchl
- Department of Anesthesia, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Constantin Lier
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Karl Rössler
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Correia P, Launay M, Balluet R, Gergele L, Gauthier V, Morel J, Beuret P, Mariat C, Thiery G, Perinel Ragey S. Towards optimization of ceftazidime dosing in obese ICU patients: the end of the 'one-size-fits-all' approach? J Antimicrob Chemother 2023; 78:2968-2975. [PMID: 37919244 DOI: 10.1093/jac/dkad339] [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: 03/22/2023] [Accepted: 10/12/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Ceftazidime is commonly used as a key antibiotic against Pseudomonas aeruginosa in critically ill patients. ICU patients have severely altered and variable antibiotic pharmacokinetics, resulting in lower antimicrobial concentrations and potentially poor outcome. Several factors, including obesity and renal function, may influence pharmacokinetics. Thus, the objective of the study was to evaluate the impact of obesity and renal function on ceftazidime plasma concentrations and dosing regimen in ICU patients. METHODS All consecutive adult patients from six ICUs, treated with continuous ceftazidime infusion and under therapeutic drug monitoring evaluation, were included. Obesity was defined as BMI ≥30 kg/m². Glomerular filtration rate (GFR) was estimated by the Chronic Kidney Disease Epidemiology Collaboration formula. The ceftazidime recommended target for plasma concentrations was between 35 and 80 mg/L. RESULTS A total of 98 patients (45 obese), with an average weight of 90 (±25) kg, were included. Mean GFR was 84.1 (±40.4) mL/min/1.73 m2. Recommended ceftazidime plasma concentrations were achieved for only 48.0% of patients, with median dosing regimen of 6 g/day. Obese patients had lower ceftazidime plasma concentrations compared with non-obese patients (37.8 versus 56.3 mg/L; P = 0.0042) despite similar dosing regimens (5.83 g/day versus 5.52 g/day, P = 0.2529). Almost all augmented renal clearance patients were underdosed despite ceftazidime dosing of 6.6 (±0.8) g/day. Weight-based ceftazidime dosing seemed to attenuate such obesity-related discrepancies, regardless of GFR. CONCLUSIONS Obese ICU patients required significantly greater ceftazidime doses to achieve the target range. A tailored dosing regimen may be considered based on weight and GFR. Future prospective studies should be performed to confirm this individualized dosing approach.
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Affiliation(s)
- Patricia Correia
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
| | - Manon Launay
- Laboratoire de Biologie-Pathologie, CHU de Saint-Etienne, Saint Etienne, France
| | - Rémi Balluet
- Laboratoire de Pharmacologie-Toxicologie-Gaz du Sang, CHU de Saint-Etienne, Avenue Albert Raymond, 42270 Saint Priest en Jarez, Saint Etienne, France
| | - Laurent Gergele
- Service de Réanimation Polyvalente, Hôpital Privé de la Loire, Saint Etienne, France
| | - Vincent Gauthier
- Service de Réanimation Polyvalente, Clinique Mutualiste, Saint Etienne, France
| | - Jérome Morel
- Service de Réanimation Polyvalente B, CHU de Saint Etienne, Saint Etienne, France
| | - Pascal Beuret
- Service de Réanimation, CHR de Roanne, Roanne, France
| | - Christophe Mariat
- Service de Réanimation Néphrologique, CHU de Saint Etienne, Saint Etienne, France
| | - Guillaume Thiery
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
- Research on Healthcare Performance RESHAPE, INSERM U1290, Université Claude Bernard Lyon, Villeurbanne, France
| | - Sophie Perinel Ragey
- Service de Médecine Intensive et Réanimation G, CHU de Saint-Etienne, Saint Etienne, France
- SAINBIOSE U1059 Research Unit, Université Jean Monnet, INSERM, Saint-Etienne, France
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5
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Fage D, Aalhoul F, Cotton F. Protein binding investigation of first-line and second-line antituberculosis drugs. Int J Antimicrob Agents 2023; 62:106999. [PMID: 37838149 DOI: 10.1016/j.ijantimicag.2023.106999] [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: 03/22/2023] [Revised: 07/11/2023] [Accepted: 10/04/2023] [Indexed: 10/16/2023]
Abstract
Data on protein binding are incomplete for first-line antituberculosis drugs, and lacking for second-line antituberculosis drugs that are used extensively for multi-drug-resistant tuberculosis (levofloxacin, linezolid and moxifloxacin). Thus, the main purposes of this study were to investigate: (i) the relationship between carrier protein concentration and drug binding; and (ii) the feasibility of predicting free drug concentration using in-vitro and in-vivo results. In-vitro experiments were performed on spiked plasma mimicking real-case samples (drug combinations from clinical practice). Median in-vivo protein binding was 1.5% for ethambutol, 9.7% for isoniazid, 0.7% for pyrazinamide and 88.2% for rifampicin; and median in-vitro protein binding was 26.2% for levofloxacin, 12.8% for linezolid and 46.3% for moxifloxacin. Albumin concentration (<30 g/L) had a moderate impact on moxifloxacin binding and a strong impact on levofloxacin, linezolid and rifampicin binding. Determination of the free drug concentration seems to be of little value for ethambutol, isoniazid, moxifloxacin and pyrazinamide; limited value for linezolid because of its low binding; and major value for rifampicin in hypoalbuminaemic patients with tuberculosis, and levofloxacin because total concentration was an inaccurate reflection of free concentration. The free concentration predicted by the mathematical model was suitable for levofloxacin and linezolid, whereas the real free concentration should be measured for rifampicin. Further investigations should be carried out to investigate the benefit of using free concentration for levofloxacin, linezolid and rifampicin, particularly in the critical period of active tuberculosis associated with hypoalbuminaemia.
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Affiliation(s)
- D Fage
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles - Universitair Laboratorium Brussel, Brussels, Belgium.
| | - F Aalhoul
- Haute Ecole Lucia de Brouckère, Brussels, Belgium
| | - F Cotton
- Department of Clinical Chemistry, Laboratoire Hospitalier Universitaire de Bruxelles - Universitair Laboratorium Brussel, Brussels, Belgium
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Saeheng T, Na-Bangchang K. Simulation of optimal dose regimens of photoactivated curcumin for antimicrobial resistance pneumonia in COVID-19 patients: A modeling approach. Infect Dis Model 2023; 8:S2468-0427(23)00046-5. [PMID: 37361409 PMCID: PMC10239661 DOI: 10.1016/j.idm.2023.05.013] [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: 08/29/2022] [Revised: 04/07/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
Background Secondary antimicrobial resistance bacterial (AMR) pneumonia could lead to an increase in mortality in COVID-19 patients, particularly of geriatric patients with underlying diseases. The comedication of current medicines for AMR pneumonia with corticosteroids may lead to suboptimal treatment or toxicities due to drug-drug interactions (DDIs). Objective This study aimed to propose new promising dosage regimens of photoactivated curcumin when co-administered with corticosteroids for the treatment of antimicrobial resistance (AMR) pneumonia in COVID-19 patients. Methods A whole-body physiologically-based pharmacokinetic (PBPK) with the simplified lung compartments model was built and verified following standard model verification (absolute average-folding error or AAFEs). The pharmacokinetic properties of photoactivated were assumed to be similar to curcumin due to minor changes in physiochemical properties of compound by photoactivation. The acceptable AAFEs values were within 2-fold. The verified model was used to simulate new regimens for different formulations of photoactivated curcumin. Results The AAFEs was 1.12-fold. Original formulation (120 mg once-daily dose) or new intramuscular nano-formulation (100 mg with a release rate of 10/h given every 7 days) is suitable for outpatients with MRSA pneumonia to improve patient adherence. New intravenous formulation (2000 mg twice-daily doses) is for hospitalized patients with both MRSA and VRSA pneumonia. Conclusion The PBPK models, in conjunction with MIC and applied physiological changes in COVID-19 patients, is a potential tool to predict optimal dosage regimens of photoactivated curcumin for the treatment of co-infected AMR pneumonia in COVID-19 patients. Each formulation is appropriate for different patient conditions and pathogens.
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Affiliation(s)
- Teerachat Saeheng
- Centre of Excellence in Pharmacology and Molecular Biology of Malaria and Cholangiocarcinoma, Chulabhorn International College, 99 Moo 18, Phaholyothin Road, Thammasat University (Rangsit Campus), Klongneung, Klongluang District, Pathumthani, 12121, Thailand
| | - Kesara Na-Bangchang
- Centre of Excellence in Pharmacology and Molecular Biology of Malaria and Cholangiocarcinoma, Chulabhorn International College, 99 Moo 18, Phaholyothin Road, Thammasat University (Rangsit Campus), Klongneung, Klongluang District, Pathumthani, 12121, Thailand
- Drug Discovery and Development Centre, Office of Advanced Science and Technology, 99 Moo 18, Phaholyothin Road, Thammasat University (Rangsit Campus), Klongneung, Klongluang, Pathumthani, 12121, Thailand
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Schulz J, Michelet R, Zeitlinger M, Mikus G, Kloft C. Microdialysis of Drug and Drug Metabolite: a Comprehensive In Vitro Analysis for Voriconazole and Voriconazole N-oxide. Pharm Res 2022; 39:2991-3003. [PMID: 36171344 PMCID: PMC9633485 DOI: 10.1007/s11095-022-03292-0] [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: 02/08/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
Purpose Voriconazole is a therapeutically challenging antifungal drug associated with high interindividual pharmacokinetic variability. As a prerequisite to performing clinical trials using the minimally-invasive sampling technique microdialysis, a comprehensive in vitro microdialysis characterization of voriconazole (VRC) and its potentially toxic N-oxide metabolite (NO) was performed. Methods The feasibility of simultaneous microdialysis of VRC and NO was explored in vitro by investigating the relative recovery (RR) of both compounds in the absence and presence of the other. The dependency of RR on compound combination, concentration, microdialysis catheter and study day was evaluated and quantified by linear mixed-effects modeling. Results Median RR of VRC and NO during individual microdialysis were high (87.6% and 91.1%). During simultaneous microdialysis of VRC and NO, median RR did not change (87.9% and 91.1%). The linear mixed-effects model confirmed the absence of significant differences between RR of VRC and NO during individual and simultaneous microdialysis as well as between the two compounds (p > 0.05). No concentration dependency of RR was found (p = 0.284). The study day was the main source of variability (46.3%) while the microdialysis catheter only had a minor effect (4.33%). VRC retrodialysis proved feasible as catheter calibration for both compounds. Conclusion These in vitro microdialysis results encourage the application of microdialysis in clinical trials to assess target-site concentrations of VRC and NO. This can support the generation of a coherent understanding of VRC pharmacokinetics and its sources of variability. Ultimately, a better understanding of human VRC pharmacokinetics might contribute to the development of personalized dosing strategies.
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Affiliation(s)
- Josefine Schulz
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gerd Mikus
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
- Department Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
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8
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Viaggi B, Cangialosi A, Langer M, Olivieri C, Gori A, Corona A, Finazzi S, Di Paolo A. Tissue Penetration of Antimicrobials in Intensive Care Unit Patients: A Systematic Review-Part II. Antibiotics (Basel) 2022; 11:antibiotics11091193. [PMID: 36139972 PMCID: PMC9495066 DOI: 10.3390/antibiotics11091193] [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: 07/23/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
In patients that are admitted to intensive care units (ICUs), the clinical outcome of severe infections depends on several factors, as well as the early administration of chemotherapies and comorbidities. Antimicrobials may be used in off-label regimens to maximize the probability of therapeutic concentrations within infected tissues and to prevent the selection of resistant clones. Interestingly, the literature clearly shows that the rate of tissue penetration is variable among antibacterial drugs, and the correlation between plasma and tissue concentrations may be inconstant. The present review harvests data about tissue penetration of antibacterial drugs in ICU patients, limiting the search to those drugs that mainly act as protein synthesis inhibitors and disrupting DNA structure and function. As expected, fluoroquinolones, macrolides, linezolid, and tigecycline have an excellent diffusion into epithelial lining fluid. That high penetration is fundamental for the therapy of ventilator and healthcare-associated pneumonia. Some drugs also display a high penetration rate within cerebrospinal fluid, while other agents diffuse into the skin and soft tissues. Further studies are needed to improve our knowledge about drug tissue penetration, especially in the presence of factors that may affect drug pharmacokinetics.
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Affiliation(s)
- Bruno Viaggi
- Department of Anesthesiology, Neuro-Intensive Care Unit, Careggi University Hospital, 50139 Florence, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Alice Cangialosi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Martin Langer
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Carlo Olivieri
- Anesthesia and Intensive Care, Sant’Andrea Hospital, ASL VC, 13100 Vercelli, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020 Ranica, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Correspondence:
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Abstract
In recent years, many studies on population pharmacokinetics of linezolid have been conducted. This comprehensive review aimed to summarize population pharmacokinetic models of linezolid, by focusing on dosage optimization to maximize the probability of attaining a certain pharmacokinetic-pharmacodynamic parameter in special populations. We searched the PubMed and EMBASE databases for population pharmacokinetic analyses of linezolid using a parametric non-linear mixed-effect approach, including both observational and prospective trials. Of the 32 studies, 26 were performed in adults, four in children, and one in both adults and children. High between-subject variability was determined in the majority of the models, which was in line with the variability of linezolid concentrations previously detected in observational studies. Some studies found that patients with renal impairment, hepatic failure, advanced age, or low body weight had higher exposure and adverse reactions rates. In contrast, lower concentrations and therapeutic failure were associated with obese patients, young patients, and patients who had undergone renal replacement techniques. In critically ill patients, the inter-individual and intra-individual variability was even greater, suggesting that this population is at an even higher risk of underexposure and overexposure. Therapeutic drug monitoring may be warranted in a large proportion of patients given that the Monte Carlo simulations demonstrated that the one-size-fits-all labeled dosing of 600 mg every 12 h could lead to toxicity or therapeutic failure for high values of the minimum inhibitory concentration of the target pathogen. Further research on covariates, including renal function, hepatic function, and drug–drug interactions related to P-glycoprotein could help to explain variability and improve linezolid dosing regimens.
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Schulz J, Michelet R, Zeitlinger M, Mikus G, Kloft C. Microdialysis of Voriconazole and its N-Oxide Metabolite: Amalgamating Knowledge of Distribution and Metabolism Processes in Humans. Pharm Res 2022; 39:3279-3291. [PMID: 36271205 PMCID: PMC9780129 DOI: 10.1007/s11095-022-03407-7] [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: 06/01/2022] [Accepted: 09/29/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE Voriconazole is an essential antifungal drug whose complex pharmacokinetics with high interindividual variability impedes effective and safe therapy. By application of the minimally-invasive sampling technique microdialysis, interstitial space fluid (ISF) concentrations of VRC and its potentially toxic N-oxide metabolite (NO) were assessed to evaluate target-site exposure for further elucidating VRC pharmacokinetics. METHODS Plasma and ISF samples of a clinical trial with an approved VRC dosing regimen were analyzed for VRC and NO concentrations. Concentration-time profiles, exposure assessed as area-under-the-curve (AUC) and metabolic ratios of four healthy adults in plasma and ISF were evaluated regarding the impact of multiple dosing and CYP2C19 genotype. RESULTS VRC and NO revealed distribution into ISF with AUC values being ≤2.82- and 17.7-fold lower compared to plasma, respectively. Intraindividual variability of metabolic ratios was largest after the first VRC dose administration while interindividual variability increased with multiple dosing. The CYP2C19 genotype influenced interindividual differences with a maximum 6- and 24-fold larger AUCNO/AUCVRC ratio between the intermediate and rapid metabolizer in plasma and ISF, respectively. VRC metabolism was saturated/auto-inhibited indicated by substantially decreasing metabolic concentration ratios with increasing VRC concentrations and after multiple dosing. CONCLUSION The feasibility of the simultaneous microdialysis of VRC and NO in vivo was demonstrated and provided new quantitative insights by leveraging distribution and metabolism processes of VRC in humans. The exploratory analysis suggested substantial dissimilarities of VRC and NO pharmacokinetics in plasma and ISF. Ultimately, a thorough understanding of target-site pharmacokinetics might contribute to the optimization of personalized VRC dosing regimens.
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Affiliation(s)
- Josefine Schulz
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Robin Michelet
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
| | - Markus Zeitlinger
- grid.22937.3d0000 0000 9259 8492Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gerd Mikus
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany ,grid.5253.10000 0001 0328 4908Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Charlotte Kloft
- grid.14095.390000 0000 9116 4836Department of Clinical Pharmacy & Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstraße 31, 12169 Berlin, Germany
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11
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van Os W, Zeitlinger M. Predicting Antimicrobial Activity at the Target Site: Pharmacokinetic/Pharmacodynamic Indices versus Time-Kill Approaches. Antibiotics (Basel) 2021; 10:antibiotics10121485. [PMID: 34943697 PMCID: PMC8698708 DOI: 10.3390/antibiotics10121485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/21/2022] Open
Abstract
Antibiotic dosing strategies are generally based on systemic drug concentrations. However, drug concentrations at the infection site drive antimicrobial effect, and efficacy predictions and dosing strategies should be based on these concentrations. We set out to review different translational pharmacokinetic-pharmacodynamic (PK/PD) approaches from a target site perspective. The most common approach involves calculating the probability of attaining animal-derived PK/PD index targets, which link PK parameters to antimicrobial susceptibility measures. This approach is time efficient but ignores some aspects of the shape of the PK profile and inter-species differences in drug clearance and distribution, and provides no information on the PD time-course. Time–kill curves, in contrast, depict bacterial response over time. In vitro dynamic time–kill setups allow for the evaluation of bacterial response to clinical PK profiles, but are not representative of the infection site environment. The translational value of in vivo time–kill experiments, conversely, is limited from a PK perspective. Computational PK/PD models, especially when developed using both in vitro and in vivo data and coupled to target site PK models, can bridge translational gaps in both PK and PD. Ultimately, clinical PK and experimental and computational tools should be combined to tailor antibiotic treatment strategies to the site of infection.
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12
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Optimizing antimicrobial use: challenges, advances and opportunities. Nat Rev Microbiol 2021; 19:747-758. [PMID: 34158654 DOI: 10.1038/s41579-021-00578-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 02/06/2023]
Abstract
An optimal antimicrobial dose provides enough drug to achieve a clinical response while minimizing toxicity and development of drug resistance. There can be considerable variability in pharmacokinetics, for example, owing to comorbidities or other medications, which affects antimicrobial pharmacodynamics and, thus, treatment success. Although current approaches to antimicrobial dose optimization address fixed variability, better methods to monitor and rapidly adjust antimicrobial dosing are required to understand and react to residual variability that occurs within and between individuals. We review current challenges to the wider implementation of antimicrobial dose optimization and highlight novel solutions, including biosensor-based, real-time therapeutic drug monitoring and computer-controlled, closed-loop control systems. Precision antimicrobial dosing promises to improve patient outcome and is important for antimicrobial stewardship and the prevention of antimicrobial resistance.
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13
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A personalised approach to antibiotic pharmacokinetics and pharmacodynamics in critically ill patients. Anaesth Crit Care Pain Med 2021; 40:100970. [PMID: 34728411 DOI: 10.1016/j.accpm.2021.100970] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/26/2021] [Accepted: 08/14/2021] [Indexed: 01/01/2023]
Abstract
Critically ill patients admitted to intensive care unit (ICU) with severe infections, or those who develop nosocomial infections, have poor outcomes with substantial morbidity and mortality. Such patients commonly have suboptimal antibiotic exposures at routinely used antibiotic doses related to an increased volume of distribution and altered clearance due to their underlying altered physiology. Furthermore, the use of extracorporeal devices such as renal replacement therapy and extracorporeal membrane oxygenation in these group of patients also has the potential to alter in vivo drug concentrations. Moreover, ICU patients are likely to be infected with less-susceptible pathogens. Therefore, one potential contributing cause to the poor outcomes observed in critically ill patients may be related to subtherapeutic antibiotic exposures. Newer concepts include the clinician considering optimised dosing based on a blood antibiotic exposure defined by pharmacokinetic modelling and therapeutic drug monitoring, combined with a knowledge of the antibiotic penetration into the site of infection, thereby achieving optimal bacterial killing. Such optimised dosing is likely to improve patient outcomes. The aim of this review is to highlight key aspects of antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in critically ill patients and provide a PK/PD approach to tailor antibiotic dosing to the individual patient.
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14
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Tietjen AK, Kroemer N, Cattaneo D, Baldelli S, Wicha SG. Population pharmacokinetics and target attainment analysis of linezolid in multidrug-resistant tuberculosis patients. Br J Clin Pharmacol 2021; 88:1835-1844. [PMID: 34622478 DOI: 10.1111/bcp.15102] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 08/31/2021] [Accepted: 09/22/2021] [Indexed: 01/02/2023] Open
Abstract
AIM This study investigates the pharmacokinetic/pharmacodynamic (PK/PD) target attainment of linezolid in patients infected with multidrug-resistant (MDR) tuberculosis (TB). METHODS A pharmacometric model was developed including 244 timed linezolid concentration samples from 39 patients employing NONMEM 7.4. The probability of target attainment (PTA, PK/PD target: unbound (f) area-under-the-concentration-time-curve (AUC)/minimal inhibitory concentration (MIC) of 119) as well as a region-specific cumulative fraction of response (CFR) were estimated for different dosing regimens. RESULTS A one-compartment model with linear elimination with a clearance (CL) of 7.69 L/h (interindividual variability 34.1%), a volume of distribution (Vd) of 45.2 L and an absorption constant (KA) of 0.679 h-1 (interoccasion variability 143.7%) allometric scaled by weight best described the PK of linezolid. The PTA at an MIC of 0.5 mg/L was 55% or 97% if patients receiving 300 or 600 mg twice daily, respectively. CFRs varied greatly among populations and geographic regions. A desirable global CFR of ≥90% was achieved if linezolid was administered at a dose of 600 mg twice daily but not at a dose of 300 mg twice daily. CONCLUSION This study showed that a dose of 300 mg twice daily of linezolid might not be sufficient to treat MDR-TB patients from a PK/PD perspective. Thus, it might be recommendable to start with a higher dose of 600 mg twice daily to ensure PK/PD target attainment. Hereby, therapeutic drug monitoring and MIC determination should be performed to control PK/PD target attainment as linezolid shows high variability in its PK in the TB population.
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Affiliation(s)
- Anna K Tietjen
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.,University of Lübeck, Lübeck, Germany
| | - Niklas Kroemer
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Sara Baldelli
- Unit of Clinical Pharmacology, Department of Laboratory Medicine, Luigi Sacco University Hospital, Milan, Italy
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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15
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Burke A, Smith D, Coulter C, Bell SC, Thomson R, Roberts JA. Clinical Pharmacokinetic and Pharmacodynamic Considerations in the Drug Treatment of Non-Tuberculous Mycobacteria in Cystic Fibrosis. Clin Pharmacokinet 2021; 60:1081-1102. [PMID: 33982266 DOI: 10.1007/s40262-021-01010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
Non-tuberculous mycobacteria (NTM) are an emerging group of pulmonary infectious pathogens of increasing importance to the management of patients with cystic fibrosis (CF). NTM include slow-growing mycobacteria such as Mycobacterium avium complex (MAC) and rapidly growing mycobacteria such as Mycobacterium abscessus. The incidence of NTM in the CF population is increasing and infection contributes to significant morbidity to the patient and costs to the health system. Treating M. abscessus requires the combination of multiple costly antibiotics for months, with potentially significant toxicity associated with treatment. Although international guidelines for the treatment of NTM infection in CF are available, there are a lack of robust pharmacokinetic studies in CF patients to inform dosing and drug choice. This paper aims to outline the pharmacokinetic and pharmacodynamic factors informing the optimal treatment of NTM infections in CF.
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Affiliation(s)
- Andrew Burke
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Daniel Smith
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Chris Coulter
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Scott C Bell
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia.,QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Rachel Thomson
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia.,Immunology Department, Gallipoli Medical Research Institute, Brisbane, QLD, Australia
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia. .,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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16
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Ogami C, Tsuji Y, Nishi Y, Kawasuji H, To H, Yamamoto Y. External Evaluation of Population Pharmacokinetics and Pharmacodynamics in Linezolid-Induced Thrombocytopenia: The Transferability of Published Models to Different Hospitalized Patients. Ther Drug Monit 2021; 43:271-278. [PMID: 33009290 DOI: 10.1097/ftd.0000000000000816] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 08/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The objective of this study was to perform an external evaluation of published linezolid population pharmacokinetic and pharmacodynamic models, to evaluate the predictive performance using an independent data set. Another aim was to offer an elegant environment for display and simulation of both the concentration and platelet count after linezolid administration. METHODS We performed a systematic literature search in PubMed for all studies evaluating the population pharmacokinetic and pharmacodynamic parameters of linezolid in patients and selected the models to be used for the external validation. The bias of predictions was visually evaluated by plotting prediction errors (PEs) and relative PEs. The precision of prediction was evaluated by calculating the mean absolute error (MAE), root mean squared error (RMSE), and mean relative error (MRE). RESULTS Three articles (models A, B, and C) provided linezolid-induced platelet dynamic models using population pharmacokinetic and pharmacodynamic modeling approaches. The PE and relative PE of both linezolid concentrations and platelet counts for models A and C showed similar predictive distributions. With respect to the prediction accuracy of total linezolid concentration, the MAE, RMSE, and MRE of population prediction values for model C was the smallest. The comparison of the MAE, RMSE, and MRE of patient-individual prediction values for the 3 pharmacodynamic models revealed no large differences. CONCLUSIONS We confirmed the transferability of published population pharmacokinetic and pharmacodynamic models and showed that they were suitable for extrapolation to other hospitals and/or patients. This study also introduced application software based on model C for the therapeutic drug monitoring of linezolid.
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Affiliation(s)
- Chika Ogami
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama
| | - Yasuhiro Tsuji
- Center for Pharmacist Education, School of Pharmacy, Nihon University, Funabashi, Chiba
| | - Yoshifumi Nishi
- Division of Hospital Safety Management, Kyorin University Hospital, Mitaka
- Department of Pharmaceutical Sciences, International University of Health and Welfare, Otawara; and
| | - Hitoshi Kawasuji
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Hideto To
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Toyama University Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
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17
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Linezolid Concentrations in Plasma and Subcutaneous Tissue are Reduced in Obese Patients, Resulting in a Higher Risk of Underdosing in Critically Ill Patients: A Controlled Clinical Pharmacokinetic Study. J Clin Med 2020; 9:jcm9041067. [PMID: 32283731 PMCID: PMC7230366 DOI: 10.3390/jcm9041067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 03/27/2020] [Accepted: 04/07/2020] [Indexed: 01/11/2023] Open
Abstract
Background: Linezolid is used for the treatment of soft tissue infections in critically ill patients. However, data for characterizing the pharmacokinetics (PK) and assessing whether effective concentrations are reached at the target site are lacking. We hypothesized that current dosing regimens do not lead to effective concentrations in the plasma and interstitial fluid (ISF) of subcutaneous tissue in obese patients. Methods: As a controlled clinical model, critically ill obese and non-obese patients undergoing intra-abdominal surgery received 600 mg linezolid as a single infusion. Concentrations in the plasma and microdialysate from the ISF of subcutaneous tissue were determined up to 8 h after dosing. Pharmacokinetic analysis was performed by non-compartmental methods. As a therapeutic target, we used fAUC/MIC > 80. Results: Fifteen obese (BMI: 48.7 ± 11.2 kg/m2) and 15 non-obese (23.9 ± 2.1 kg/m2) patients were analyzed. AUC0–8 in ISF decreased by −1.69 mg*h/L (95% CI: −2.59 to −0.79, p < 0.001) for every 10 kg increase in weight. PK in obese patients were characterized by lower maximal plasma concentrations (median 3.8 vs. 8.3 mg/L, p < 0.001) and a higher volume of distribution (41.0 vs. 30.8 L, p < 0.001), and the therapeutic target was not reached for MIC ≥ 1 mg/L in ISF and ≥ 2 mg/L in plasma. Conclusions: Increasing the weight led to a decrease of linezolid concentrations in the plasma and subcutaneous tissue. The current dosing regimen does not seem to produce sufficient concentrations to kill bacteria with MIC ≥ 2 mg/L, especially as empirical antimicrobial therapy in critically ill obese patients.
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18
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Barrasa H, Soraluce A, Usón E, Sainz J, Martín A, Sánchez-Izquierdo JÁ, Maynar J, Rodríguez-Gascón A, Isla A. Impact of augmented renal clearance on the pharmacokinetics of linezolid: Advantages of continuous infusion from a pharmacokinetic/pharmacodynamic perspective. Int J Infect Dis 2020; 93:329-338. [PMID: 32112965 DOI: 10.1016/j.ijid.2020.02.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES The aim of this study was to assess the influence of renal function, in particular the presence of augmented renal clearance (ARC), on the pharmacokinetics of linezolid in critically ill patients. The effect of continuous infusion on the probability of therapeutic success from a pharmacokinetic/pharmacodynamic (PK/PD) perspective was also evaluated. METHODS Seventeen patients received linezolid (600 mg every 12 h) as a 30-min infusion and 26 as a continuous infusion (50 mg/h). The PK parameters were calculated and the probability of PK/PD target attainment (PTA) was estimated by Monte Carlo simulation (MCS) for different doses administered by intermittent (600 mg every 12 h or 600 mg every 8 h) or continuous infusion (50 mg/h or 75 mg/h). RESULTS In patients without ARC, the standard dose was adequate to attain the PK/PD target. However, linezolid clearance was significantly higher in ARC patients, leading to sub-therapeutic concentrations. Continuous infusion (50 mg/h) provided concentrations ≥2 mg/l in 70% of the ARC patients. MCS revealed that concentrations ≥2 mg/l would be reached in >90% of patients receiving 75 mg/h. CONCLUSIONS ARC increases linezolid clearance and leads to a high risk of underexposure with the standard dose. Continuous infusion increases the PTA, but an infusion rate of 75 mg/h should be considered to ensure concentrations ≥2 mg/ml.
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Affiliation(s)
- Helena Barrasa
- Intensive Care Unit, University Hospital of Alava, C/ Olaguibel 29, Vitoria-Gasteiz, Spain
| | - Amaia Soraluce
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Elena Usón
- Intensive Care Unit, University Hospital of Alava, C/ Olaguibel 29, Vitoria-Gasteiz, Spain
| | - Javier Sainz
- Intensive Care Unit, Doce de Octubre Hospital, Avda de Córdoba s/n, Madrid, Spain
| | - Alejandro Martín
- Intensive Care Unit, University Hospital of Alava, C/ Olaguibel 29, Vitoria-Gasteiz, Spain
| | | | - Javier Maynar
- Intensive Care Unit, University Hospital of Alava, C/ Olaguibel 29, Vitoria-Gasteiz, Spain
| | - Alicia Rodríguez-Gascón
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain
| | - Arantxazu Isla
- Pharmacokinetics, Nanotechnology and Gene Therapy Group, Faculty of Pharmacy, Centro de Investigación Lascaray-ikergunea, University of the Basque Country UPV/EHU, Vitoria-Gasteiz, Spain.
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19
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Nowak H, Weidemann C, Martini S, Oesterreicher ZA, Dorn C, Adamzik M, Kees F, Zeitlinger M, Rahmel T. Repeated determination of moxifloxacin concentrations in interstitial space fluid of muscle and subcutis in septic patients. J Antimicrob Chemother 2019; 74:2681-2689. [PMID: 31299075 DOI: 10.1093/jac/dkz259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/07/2019] [Accepted: 05/22/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND For an effective antimicrobial treatment, it is crucial that antibiotics reach sufficient concentrations in plasma and tissue. Currently no data exist regarding moxifloxacin plasma concentrations and exposure levels in tissue under septic conditions. OBJECTIVES To determine the pharmacokinetics of moxifloxacin in plasma and interstitial space fluid over a prolonged period. PATIENTS AND METHODS Ten septic patients were treated with 400 mg of moxifloxacin once a day; on days 1, 3 and 5 of treatment plasma sampling and microdialysis in the subcutis and muscle of the upper thigh were performed to determine concentrations of moxifloxacin in different compartments. This trial was registered in the German Clinical Trials Register (DRKS, register number DRKS00012985). RESULTS Mean unbound fraction of moxifloxacin in plasma was 85.5±3.4%. On day 1, Cmax in subcutis and muscle was 2.8±1.8 and 2.5±1.3 mg/L, respectively, AUC was 24.8±15.1 and 21.3±10.5 mg·h/L, respectively, and fAUC0-24/MIC was 100.9±62.9 and 86.5±38.3 h, respectively. Cmax for unbound moxifloxacin in plasma was 3.5±0.9 mg/L, AUC was 23.5±7.5 mg·h/L and fAUC0-24/MIC was 91.6±24.8 h. Key pharmacokinetic parameters on days 3 and 5 showed no significant differences. Clearance was higher than in healthy adults, but tissue concentrations were comparable, most likely due to a lower protein binding. CONCLUSIONS Surprisingly, the first dose already achieved exposure comparable to steady-state conditions. The approved daily dose of 400 mg was adequate in our patient population. Thus, it seems that in septic patients a loading dose on the first day of treatment with moxifloxacin is not required.
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Affiliation(s)
- Hartmuth Nowak
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Caroline Weidemann
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Stefan Martini
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Zoe Anne Oesterreicher
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Michael Adamzik
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Universitaetsstr. 31, D Regensburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, A Vienna, Austria
| | - Tim Rahmel
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, In der Schornau 23-25, D Bochum, Germany
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20
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Schulz J, Kluwe F, Mikus G, Michelet R, Kloft C. Novel insights into the complex pharmacokinetics of voriconazole: a review of its metabolism. Drug Metab Rev 2019; 51:247-265. [PMID: 31215810 DOI: 10.1080/03602532.2019.1632888] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Voriconazole, a second-generation triazole frequently used for the prophylaxis and treatment of invasive fungal infections, undergoes complex metabolism mainly involving various (polymorphic) cytochrome P450 enzymes in humans. Although high inter- and intraindividual variability in voriconazole pharmacokinetics have been observed and the therapeutic range for this compound is relatively narrow, the metabolism of voriconazole has not been fully elucidated yet. The available literature data investigating the multiple different pathways and metabolites are extremely unbalanced and thus the absolute or relative contribution of the different pathways and enzymes involved in the metabolism of voriconazole remains uncertain. Furthermore, other factors such as nonlinear pharmacokinetics caused by auto-inhibition or -induction and polymorphisms of the metabolizing enzymes hinder safe and effective voriconazole dosing in clinical practice and have not yet been studied sufficiently. This review aimed at amalgamating the available literature on the pharmacokinetics of voriconazole in vitro and in vivo, with a special focus on metabolism in adults and children, in order to congregate an overall landscape of the current body of knowledge and identify knowledge gaps, opening the way towards further research in order to foster the understanding, towards better therapeutic dosing decisions.
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Affiliation(s)
- Josefine Schulz
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany
| | - Franziska Kluwe
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany.,Graduate Research Training Program PharMetrX , Berlin/Potsdam , Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg , Heidelberg , Germany
| | - Robin Michelet
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin , Berlin , Germany
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21
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Wang D, Zheng X, Yang Y, Chen X. Population pharmacokinetic analysis of linezolid in patients with different types of shock: Effect of platelet count. Exp Ther Med 2019; 18:1786-1792. [PMID: 31410138 PMCID: PMC6676194 DOI: 10.3892/etm.2019.7747] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/24/2019] [Indexed: 11/06/2022] Open
Abstract
Linezolid was approved by the Food and Drug Administration for the treatment of serious infections. However, patients with serious frequently develop shock, and it is currently elusive whether shock affects the pharmacokinetics of linezolid. The aim of the present study was to explore whether the pharmacokinetics of linezolid are different among patients with various types of shock or patients without shock and whether potential confounders are involved in their outcomes. A population pharmacokinetic analysis using a non-linear mixed-effects model was performed to examine the pharmacokinetics of patients with different types of shock or patients without shock. The pharmacokinetics of linezolid in patients with different types of shock or patients without shock was described by a one-compartment model. In our results, the patients with different types of shock or patients without shock demonstrated no differences in pharmacokinetics, whereas the platelet count was identified as a significant influencing factor. The results demonstrated that the pharmacokinetics of linezolid exhibited no significant differences among patients with different types of shock or patients without shock, whereas the platelet count significantly affected the clearance rate of linezolid.
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Affiliation(s)
- Dongdong Wang
- Department of Pharmacy, Children's Hospital of Fudan University, Shanghai 201102, P.R. China
| | - Xiaofei Zheng
- Department of Medical Imaging, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu 210000, P.R. China
| | - Yang Yang
- Jiangsu Key Laboratory of New Drug Research and Clinical Pharmacy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, P.R. China
| | - Xiao Chen
- Department of Pharmacy, The People's Hospital of Jiangyin, Jiangyin, Jiangsu 214400, P.R. China
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Roger C, Roberts JA, Muller L. Clinical Pharmacokinetics and Pharmacodynamics of Oxazolidinones. Clin Pharmacokinet 2019; 57:559-575. [PMID: 29063519 DOI: 10.1007/s40262-017-0601-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Oxazolidinones are a class of synthetic antimicrobial agents with potent activity against a wide range of multidrug-resistant Gram-positive pathogens including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. Oxazolidinones exhibit their antibacterial effects by inhibiting protein synthesis acting on the ribosomal 50S subunit of the bacteria and thus preventing formation of a functional 70S initiation complex. Currently, two oxazolidinones have been approved by the US Food and Drug Administration: linezolid and more recently tedizolid. Other oxazolidinones are currently under investigation in clinical trials. These antimicrobial agents exhibit a favourable pharmacokinetic profile with an excellent bioavailability and a good tissue and organ penetration. In-vitro susceptibility studies have shown that oxazolidinones are bacteriostatic against enterococci and staphylococci, and bactericidal for the majority of strains of streptococci. In the context of emergence of resistance to glycopeptides, oxazolidinones have become an effective alternative to vancomycin treatment frequently associated with nephrotoxicity. However, oxazolidinones, and linezolid in particular, are associated with significant adverse events, myelosuppression representing the main unfavourable side effect. More recently, tedizolid has been shown to effectively treat acute bacterial skin and skin structure infections. This newer oxazolidinone offers the advantages of once-daily dosing and a better safety profile in healthy volunteer studies (fewer gastrointestinal and haematological side effects). The potential use of tedizolid for other infections that could require longer therapy warrants further studies for positioning this new oxazolidinone in the available antimicrobial armamentarium. Moreover, other oxazolidinones are currently under active investigation.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France.
- EA 2992, Faculty of Medicine, Montpellier-Nimes University, Nîmes, France.
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia.
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Womens' Hospital, Brisbane, QLD, Australia
| | - Laurent Muller
- Department of Anesthesiology, Intensive Care, Pain and Emergency Medicine, Nîmes University Hospital, Place du Professeur Robert Debré, 30 029, Nîmes cedex 9, France
- EA 2992, Faculty of Medicine, Montpellier-Nimes University, Nîmes, France
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23
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Jaruratanasirikul S, Nitchot W, Wongpoowarak W, Samaeng M, Nawakitrangsan M. Population pharmacokinetics and Monte Carlo simulations of sulbactam to optimize dosage regimens in patients with ventilator-associated pneumonia caused by Acinetobacter baumannii. Eur J Pharm Sci 2019; 136:104940. [DOI: 10.1016/j.ejps.2019.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 05/08/2019] [Accepted: 05/23/2019] [Indexed: 11/29/2022]
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24
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Simon P, Petroff D, Dorn C, Ehmann L, Kloft C, Prettin C, Dietrich A, Zeitlinger M, Kees F, Wrigge H. Measurement of soft tissue drug concentrations in morbidly obese and non-obese patients - A prospective, parallel group, open-labeled, controlled, phase IV, single center clinical trial. Contemp Clin Trials Commun 2019; 15:100375. [PMID: 31193565 PMCID: PMC6535681 DOI: 10.1016/j.conctc.2019.100375] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/17/2019] [Accepted: 05/05/2019] [Indexed: 12/17/2022] Open
Abstract
Background Pharmacokinetic (PK) and pharmacodynamic (PD) data on perioperative antibiotic prophylaxis or antibiotic therapy are rare in patients suffering from morbid obesity. Furthermore, dosing regimens should be based on PK/PD models that ensure effective antibiotic exposure not in plasma, but primarily at the site of infection, mostly in the interstitial fluid (ISF). The aim of this trial is to investigate whether current dosing regimens of various antibiotics lead to effective concentrations in the ISF of morbidly obese patients. Methods We designed a prospective, parallel group, open-labeled, controlled single center trial to investigate the plasma and tissue pharmacokinetics of the antibiotics linezolid, meropenem, tigecycline, piperacillin/tazobactam, fosfomcyine, cefazolin, metronidazole and as secondary aim the analgesics metamizole and acetaminophen. Inclusion criteria comprise body mass index ≥35 kg/m2 for obese or between 18.5 and 30 kg/m2 for non-obese patients scheduled for elective abdominal surgery. For PK analysis, blood and microdialysate samples of subcutaneous tissue were collected 0–8 h after study drug administration. The primary endpoint is to investigate a possible dependency of the area-under-the-curve (AUC0-8) in the interstitial fluid on body weight and obesity with population based pharmacokinetic analysis. Discussion Inadequate dosing regimes of antibiotics may be a relevant factor for morbidity and mortality of patients, as well as for the development of bacterial antibiotic resistance. The measurement of plasma and tissue concentrations will provide information necessary for PK/PD-modelling. These data about antibiotic PK/PDcharacteristics in soft tissue and their dependence on weight should help to develop weight-dependent models for calculation of patient's individual doses of different antibiotics. Trial registration EU clinical trials register (EudraCT-No. 2012-004383-22) and German Clinical trials Register (DRKS00004776);
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Affiliation(s)
- P Simon
- University of Leipzig, Department of Anaesthesiology and Intensive Care Medicine, Leipzig, Germany.,University of Leipzig, Integrated Research and Treatment Center (IFB) Adiposity Diseases, Leipzig, Germany
| | - D Petroff
- University of Leipzig, Clinical Trial Centre Leipzig, Germany
| | - C Dorn
- University of Regensburg, Institute of Pharmacy, Regensburg, Germany
| | - L Ehmann
- Freie Universitaet Berlin, Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Berlin, Germany
| | - C Kloft
- Freie Universitaet Berlin, Institute of Pharmacy, Department of Clinical Pharmacy and Biochemistry, Berlin, Germany
| | - C Prettin
- University of Leipzig, Clinical Trial Centre Leipzig, Germany
| | - A Dietrich
- University of Leipzig, Integrated Research and Treatment Center (IFB) Adiposity Diseases, Leipzig, Germany.,University of Leipzig, Department of Visceral, Transplantation, Vascular and Thoracic Surgery, Leipzig, Germany
| | - M Zeitlinger
- Medical University of Vienna, Department of Clinical Pharmacology, Vienna, Austria
| | - F Kees
- University of Regensburg, Department of Pharmacology, Regensburg, Germany
| | - H Wrigge
- University of Leipzig, Department of Anaesthesiology and Intensive Care Medicine, Leipzig, Germany.,University of Leipzig, Integrated Research and Treatment Center (IFB) Adiposity Diseases, Leipzig, Germany.,Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Germany
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25
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Burau D, Petroff D, Simon P, Ehmann L, Weiser C, Dorn C, Kratzer A, Wrigge H, Kloft C. Drug combinations and impact of experimental conditions on relative recovery in in vitro microdialysis investigations. Eur J Pharm Sci 2019; 127:252-260. [DOI: 10.1016/j.ejps.2018.10.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/26/2018] [Accepted: 10/30/2018] [Indexed: 12/17/2022]
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26
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Zhou YF, Xiong YQ, Tao MT, Li L, Bu MX, Sun J, Liao XP, Liu YH. Increased activity of linezolid in combination with rifampicin in a murine pneumonia model due to MRSA. J Antimicrob Chemother 2018; 73:1899-1907. [DOI: 10.1093/jac/dky129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/15/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yu-Feng Zhou
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Yan Q Xiong
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Meng-Ting Tao
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Liang Li
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Ming-Xiao Bu
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Jian Sun
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Xiao-Ping Liao
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
| | - Ya-Hong Liu
- National Risk Assessment Laboratory for Antimicrobial Resistance of Animal Original Bacteria, South China Agricultural University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Veterinary Pharmaceutics Development and Safety Evaluation, South China Agricultural University, Guangzhou, China
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27
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Minichmayr IK, Schaeftlein A, Kuti JL, Zeitlinger M, Kloft C. Clinical Determinants of Target Non-Attainment of Linezolid in Plasma and Interstitial Space Fluid: A Pooled Population Pharmacokinetic Analysis with Focus on Critically Ill Patients. Clin Pharmacokinet 2018; 56:617-633. [PMID: 27753002 DOI: 10.1007/s40262-016-0463-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES We aimed to assess linezolid pharmacokinetics in the plasma and interstitial space fluid (ISF) of patients with sepsis, diabetic foot infections or cystic fibrosis and healthy volunteers. The impacts of joint characteristics and disease on plasma and target-site exposure were to be identified together with the benefit of dose intensification in critically ill patients. METHODS Rich plasma (n = 1598) and ISF concentrations in subcutaneous adipose (n = 1430) and muscle tissue (n = 1089) measured by microdialysis were pooled from three clinical trials with 51 individuals receiving 600 mg of intravenous and oral linezolid. All data were analysed simultaneously by a population approach also considering methodological aspects of microdialysis. The impact of covariates on the attainment of the pharmacokinetic/pharmacodynamic targets, AUC/MIC = 100 (area under the concentration-time curve/minimum inhibitory concentration) and fT>MIC = 99 % (time that unbound concentrations exceed the MIC), was assessed by deterministic and Monte Carlo simulations. RESULTS A two-compartment pharmacokinetic model with nonlinear elimination and tissue distribution factors accounting for differences between plasma and ISF concentrations adequately predicted all measurements. Clearance (CL) was highest in septic patients (11.2 L/h vs. CLHealthy/CLCystic fibrosis/CLDiabetic = 7.67/6.87/6.35 L/h). Penetration into subcutaneous adipose ISF was lowest in diabetic patients (-34.9 % compared with healthy volunteers). Creatinine clearance and total body weight further impacted linezolid exposure. To achieve timely efficacious therapy, front-loaded dosing and continuous infusion seemed beneficial in septic patients. CONCLUSIONS Our analysis suggests that after standard linezolid doses, particularly patients with sepsis and conserved renal function are at risk of not attaining pharmacokinetic/pharmacodynamic targets and would benefit from initial dose intensification.
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Affiliation(s)
- Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - André Schaeftlein
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Berlin, Germany
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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28
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Variable Linezolid Exposure in Intensive Care Unit Patients-Possible Role of Drug-Drug Interactions. Ther Drug Monit 2017; 38:573-8. [PMID: 27631464 DOI: 10.1097/ftd.0000000000000324] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard doses of linezolid may not be suitable for all patient groups. Intensive care unit (ICU) patients in particular may be at risk of inadequate concentrations. This study investigated variability of drug exposure and its potential sources in this population. METHODS Plasma concentrations of linezolid were determined by high-performance liquid chromatography in a convenience sample of 20 ICU patients treated with intravenous linezolid 600 mg twice daily. Ultrafiltration applying physiological conditions (pH 7.4/37°C) was used to determine the unbound fraction. Individual pharmacokinetic (PK) parameters were estimated by population PK modeling. As measures of exposure to linezolid, area under the concentration-time curve (AUC) and trough concentrations (Cmin) were calculated and compared with published therapeutic ranges (AUC 200-400 mg*h/L, Cmin 2-10 mg/L). Coadministered inhibitors or inducers of cytochrome P450 and/or P-glycoprotein were noted. RESULTS Data from 18 patients were included into the PK evaluation. Drug exposure was highly variable (median, range: AUC 185, 48-618 mg*h/L, calculated Cmin 2.92, 0.0062-18.9 mg/L), and only a minority of patients had values within the target ranges (6 and 7, respectively). AUC and Cmin were linearly correlated (R = 0.98), and classification of patients (underexposed/within therapeutic range/overexposed) according to AUC or Cmin was concordant in 15 cases. Coadministration of inhibitors was associated with a trend to higher drug exposure, whereas 3 patients treated with levothyroxine showed exceedingly low drug exposure (AUC ∼60 mg*h/L, Cmin <0.4 mg/L). The median unbound fraction in all 20 patients was 90.9%. CONCLUSIONS Drug exposure after standard doses of linezolid is highly variable and difficult to predict in ICU patients, and therapeutic drug monitoring seems advisable. PK drug-drug interactions might partly be responsible and should be further investigated; protein binding appears to be stable and irrelevant.
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29
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Schwameis R, Syré S, Sarahrudi K, Appelt A, Marhofer D, Burau D, Kloft C, Zeitlinger M. Penetration of linezolid into synovial fluid and muscle tissue after elective arthroscopy. J Antimicrob Chemother 2017; 72:2817-2822. [DOI: 10.1093/jac/dkx219] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 06/08/2017] [Indexed: 01/02/2023] Open
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30
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Wicha SG, Huisinga W, Kloft C. Translational Pharmacometric Evaluation of Typical Antibiotic Broad-Spectrum Combination Therapies Against Staphylococcus Aureus Exploiting In Vitro Information. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2017; 6:512-522. [PMID: 28378945 PMCID: PMC5572409 DOI: 10.1002/psp4.12197] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/24/2017] [Accepted: 03/29/2017] [Indexed: 11/15/2022]
Abstract
Broad‐spectrum antibiotic combination therapy is frequently applied due to increasing resistance development of infective pathogens. The objective of the present study was to evaluate two common empiric broad‐spectrum combination therapies consisting of either linezolid (LZD) or vancomycin (VAN) combined with meropenem (MER) against Staphylococcus aureus (S. aureus) as the most frequent causative pathogen of severe infections. A semimechanistic pharmacokinetic‐pharmacodynamic (PK‐PD) model mimicking a simplified bacterial life‐cycle of S. aureus was developed upon time‐kill curve data to describe the effects of LZD, VAN, and MER alone and in dual combinations. The PK‐PD model was successfully (i) evaluated with external data from two clinical S. aureus isolates and further drug combinations and (ii) challenged to predict common clinical PK‐PD indices and breakpoints. Finally, clinical trial simulations were performed that revealed that the combination of VAN‐MER might be favorable over LZD‐MER due to an unfavorable antagonistic interaction between LZD and MER.
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Affiliation(s)
- S G Wicha
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - W Huisinga
- Institute of Mathematics, University of Potsdam, Potsdam-Golm, Germany
| | - C Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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31
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Yamashina T, Tsuruyama M, Odawara M, Tsuruta M, Miyata H, Kozono A, Tsuji Y, Miyoshi T, Kawamata Y, Hiraki Y. Pharmacokinetics of linezolid during continuous hemodiafiltration: A case report. J Infect Chemother 2017; 23:709-712. [PMID: 28408302 DOI: 10.1016/j.jiac.2017.03.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 02/23/2017] [Accepted: 03/18/2017] [Indexed: 11/25/2022]
Abstract
The pharmacokinetics of linezolid clearance (CLLZD) during continuous hemodiafiltration (CHDF) has not been comprehensively analyzed. Here, we examined CLLZD by CHDF in a patient with septic shock and disseminated intravascular coagulation due to methicillin-resistant Staphylococcus aureus. The extraction ratio of LZD by CHDF was 22.6%, and the protein-binding rate was 17.9% ± 7.7%. In addition, it was determined that the calculated total body clearance of LZD was 30.2 mL/min, plasma elimination half-life was 8.66 h, and the CLLZD by the dialyzer used for CHDF was 23.0 mL/min. From the obtained pharmacokinetics, the CLLZD of patients continuing CHDF was estimated to be approximately half of the reported CLLZD for healthy subjects. In addition, the LZD concentration of the sepsis patient who underwent CHDF remained higher than the minimum inhibitory concentration and was similar to the LZD concentrations reported in normal renal function patients. Although further studies are warranted, when LZD is administered to patients treated with CHDF, the present findings suggest that dose regulation is not required.
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Affiliation(s)
- Takuya Yamashina
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan.
| | - Moeko Tsuruyama
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan
| | - Miki Odawara
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan
| | - Minako Tsuruta
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan
| | - Hirochika Miyata
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan
| | - Aki Kozono
- Department of Pharmacy, National Hospital Organization Kumamoto Saisyunsou Hospital, 2659 Suya, Goushi City, Kumamoto 861-1196, Japan
| | - Yasuhiro Tsuji
- Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, 2630 Sugitani, Toyama City, Toyama 930-0194, Japan
| | - Takanori Miyoshi
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan
| | - Yosei Kawamata
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan
| | - Yoichi Hiraki
- Department of Pharmacy, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu City, Oita 874-0011, Japan
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Tsuji Y, Holford NHG, Kasai H, Ogami C, Heo YA, Higashi Y, Mizoguchi A, To H, Yamamoto Y. Population pharmacokinetics and pharmacodynamics of linezolid-induced thrombocytopenia in hospitalized patients. Br J Clin Pharmacol 2017; 83:1758-1772. [PMID: 28186644 DOI: 10.1111/bcp.13262] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/09/2017] [Accepted: 02/03/2017] [Indexed: 01/10/2023] Open
Abstract
AIMS Thrombocytopenia is among the most important adverse effects of linezolid treatment. Linezolid-induced thrombocytopenia incidence varies considerably but has been associated with impaired renal function. We investigated the pharmacodynamic mechanism (myelosuppression or enhanced platelet destruction) and the role of impaired renal function (RF) in the development of thrombocytopenia. METHODS The pharmacokinetics of linezolid were described with a two-compartment distribution model with first-order absorption and elimination. RF was calculated using the expected creatinine clearance. The decrease platelets by linezolid exposure was assumed to occur by one of two mechanisms: inhibition of the formation of platelets (PDI) or stimulation of the elimination (PDS) of platelets. RESULTS About 50% of elimination was found to be explained by renal clearance (normal RF). The population mean estimated plasma protein binding of linezolid was 18% [95% confidence interval (CI) 16%, 20%] and was independent of the observed concentrations. The estimated mixture model fraction of patients with a platelet count decreased due to PDI was 0.97 (95% CI 0.87, 1.00), so the fraction due to PDS was 0.03. RF had no influence on linezolid pharmacodynamics. CONCLUSION We have described the influence of weight, renal function, age and plasma protein binding on the pharmacokinetics of linezolid. This combined pharmacokinetic, pharmacodynamic and turnover model identified that the most common mechanism of thrombocytopenia associated with linezolid is PDI. Impaired RF increases thrombocytopenia by a pharmacokinetic mechanism. The linezolid dose should be reduced in RF.
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Affiliation(s)
- Yasuhiro Tsuji
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama, Japan.,Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Nicholas H G Holford
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Hidefumi Kasai
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama, Japan.,Certara G.K., Tokyo, Japan
| | - Chika Ogami
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Young-A Heo
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Yoshitsugu Higashi
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama, Japan
| | - Akiko Mizoguchi
- Department of Pharmacy, Sasebo Chuo Hospital, Nagasaki, Japan
| | - Hideto To
- Department of Medical Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Yoshihiro Yamamoto
- Department of Clinical Infectious Diseases, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama, Japan
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Unbound fraction of fluconazole and linezolid in human plasma as determined by ultrafiltration: Impact of membrane type. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1039:74-78. [PMID: 27825625 DOI: 10.1016/j.jchromb.2016.10.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 10/13/2016] [Accepted: 10/29/2016] [Indexed: 11/21/2022]
Abstract
Ultrafiltration is a rapid and convenient method to determine the free concentrations of drugs in plasma. Several ultrafiltration devices based on Eppendorf cups are commercially available, but are not validated for such use by the manufacturer. Plasma pH, temperature and relative centrifugal force as well as membrane type can influence the results. In the present work, we developed an ultrafiltration method in order to determine the free concentrations of linezolid or fluconazole, both neutral and moderately lipophilic antiinfective drugs for parenteral as well as oral administration, in plasma of patients. Whereas both substances behaved relatively insensitive in human plasma regarding variations in pH (7.0-8.5), temperature (5-37°C) or relative centrifugal force (1000-10.000xg), losses of linezolid were observed with the Nanosep Omega device due to adsorption onto the polyethersulfone membrane (unbound fraction 75% at 100mg/L and 45% at 0.1mg/L, respectively). No losses were observed with Vivacon which is equipped with a membrane of regenerated cellulose. With fluconazole no differences between Nanosep and Vivacon were observed. Applying standard conditions (pH 7.4/37°C/1000xg/20min), the mean unbound fraction of linezolid in pooled plasma from healthy volunteers was 81.5±2.8% using Vivacon, that of fluconazole was 87.9±3.5% using Nanosep or 89.4±3.3% using Vivacon. The unbound fraction of linezolid was 85.4±3.7% in plasma samples from surgical patients and 92.1±6.2% in ICU patients, respectively. The unbound fraction of fluconazole was 93.9±3.3% in plasma samples from ICU patients.
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34
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Wicha SG, Kloft C. Simultaneous determination and stability studies of linezolid, meropenem and vancomycin in bacterial growth medium by high-performance liquid chromatography. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1028:242-248. [DOI: 10.1016/j.jchromb.2016.06.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/16/2016] [Accepted: 06/19/2016] [Indexed: 10/21/2022]
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Sazdanovic P, Jankovic SM, Kostic M, Dimitrijevic A, Stefanovic S. Pharmacokinetics of linezolid in critically ill patients. Expert Opin Drug Metab Toxicol 2016; 12:595-600. [PMID: 27020789 DOI: 10.1517/17425255.2016.1170807] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Linezolid is an oxazolidinone antibiotic active against Gram-positive bacteria, and is most commonly used to treat life-threatening infections in critically ill patients. The pharmacokinetics of linezolid are profoundly altered in critically ill patients, partly due to decreased function of vital organs, and partly because life-sustaining drugs and devices may change the extent of its excretion. AREAS COVERED This article is summarizes key changes in the pharmacokinetics of linezolid in critically ill patients. The changes summarized are clinically relevant and may serve as rationale for dosing recommendations in this particular population. EXPERT OPINION While absorption and penetration of linezolid to tissues are not significantly changed in critically ill patients, protein binding of linezolid is decreased, volume of distribution increased, and metabolism may be inhibited leading to non-linear kinetics of elimination; these changes are responsible for high inter-individual variability of linezolid plasma concentrations, which requires therapeutic plasma monitoring and choice of continuous venous infusion as the administration method. Acute renal or liver failure decrease clearance of linezolid, but renal replacement therapy is capable of restoring clearance back to normal, obviating the need for dosage adjustment. More population pharmacokinetic studies are necessary which will identify and quantify the influence of various factors on clearance and plasma concentrations of linezolid in critically ill patients.
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Affiliation(s)
- Predrag Sazdanovic
- a Gynecology and Obstetrics, Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Slobodan M Jankovic
- b Pharmacology, Toxicology and Clinical Pharmacy, Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Marina Kostic
- c Pharmacology and Toxicology, Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Aleksandra Dimitrijevic
- a Gynecology and Obstetrics, Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Srdjan Stefanovic
- d Clinical Pharmacy, Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
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Maseda E, Gimenez MJ, Gilsanz F, Aguilar L. Basis for selecting optimum antibiotic regimens for secondary peritonitis. Expert Rev Anti Infect Ther 2015; 14:109-24. [PMID: 26568097 DOI: 10.1586/14787210.2016.1120669] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Adequate management of severely ill patients with secondary peritonitis requires supportive therapy of organ dysfunction, source control of infection and antimicrobial therapy. Since secondary peritonitis is polymicrobial, appropriate empiric therapy requires combination therapy in order to achieve the needed coverage for both common and more unusual organisms. This article reviews etiological agents, resistance mechanisms and their prevalence, how and when to cover them and guidelines for treatment in the literature. Local surveillances are the basis for the selection of compounds in antibiotic regimens, which should be further adapted to the increasing number of patients with risk factors for resistance (clinical setting, comorbidities, previous antibiotic treatments, previous colonization, severity…). Inadequate antimicrobial regimens are strongly associated with unfavorable outcomes. Awareness of resistance epidemiology and of clinical consequences of inadequate therapy against resistant bacteria is crucial for clinicians treating secondary peritonitis, with delicate balance between optimization of empirical therapy (improving outcomes) and antimicrobial overuse (increasing resistance emergence).
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Affiliation(s)
- Emilio Maseda
- a Anesthesiology and Surgical Critical Care Department , Hospital Universitario La Paz , Madrid , Spain
| | | | - Fernando Gilsanz
- a Anesthesiology and Surgical Critical Care Department , Hospital Universitario La Paz , Madrid , Spain
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Ray A, Malin D, Nicolau DP, Wiskirchen DE. Antibiotic Tissue Penetration in Diabetic Foot Infections A Review of the Microdialysis Literature and Needs for Future Research. J Am Podiatr Med Assoc 2015; 105:520-31. [PMID: 26667505 DOI: 10.7547/14-036.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Although many antimicrobial agents display good in vitro activity against the pathogens frequently implicated in diabetic foot infections, effective treatment can be complicated by reduced tissue penetration in this population secondary to peripheral arterial disease and emerging antimicrobial resistance, which can result in clinical failure. Improved characterization of antibiotic tissue pharmacokinetics and penetration ratios in diabetic foot infections is needed. Microdialysis offers advantages over the skin blister and tissue homogenate studies historically used to define antibiotic penetration in skin and soft-tissue infections by defining antibiotic penetration into the interstitial fluid over the entire concentration versus time profile. However, only a select number of agents currently recommended for treating diabetic foot infections have been evaluated using these methods, which are described herein. Better characterization of the tissue penetration of antibiotic agents is needed for the development of methods for maximizing the pharmacodynamic profile of these agents to ultimately improve treatment outcomes for patients with diabetic foot infections.
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Affiliation(s)
- Amanda Ray
- Section of Podiatric Surgery, Department of Surgery, Saint Francis Hospital and Medical Center, Hartford, CT
| | - Danielle Malin
- Section of Podiatric Surgery, Department of Surgery, Saint Francis Hospital and Medical Center, Hartford, CT
| | - David P. Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT
- Division of Infectious Diseases, Hartford Hospital, Hartford, CT
| | - Dora E. Wiskirchen
- Department of Pharmacy Practice and Administration, School of Pharmacy, University of Saint Joseph, Hartford, CT
- Department of Pharmacy, Saint Francis Hospital and Medical Center, Hartford, CT
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38
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Hites M, Taccone FS. Optimization of antibiotic therapy in the obese, critically ill patient. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13546-015-1060-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Liu X, Kruger P, Maibach H, Colditz PB, Roberts MS. Using skin for drug delivery and diagnosis in the critically ill. Adv Drug Deliv Rev 2014; 77:40-9. [PMID: 25305335 DOI: 10.1016/j.addr.2014.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 09/09/2014] [Accepted: 10/01/2014] [Indexed: 02/08/2023]
Abstract
Skin offers easy access, convenience and non-invasiveness for drug delivery and diagnosis. In principle, these advantages of skin appear to be attractive for critically ill patients given potential difficulties that may be associated with oral and parenteral access in these patients. However, the profound changes in skin physiology that can be seen in these patients provide a challenge to reliably deliver drugs or provide diagnostic information. Drug delivery through skin may be used to manage burn injury, wounds, infection, trauma and the multisystem complications that rise from these conditions. Local anaesthetics and analgesics can be delivered through skin and may have wide application in critically ill patients. To ensure accurate information, diagnostic tools require validation in the critically ill patient population as information from other patient populations may not be applicable.
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40
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Luque S, Grau S, Alvarez-Lerma F, Ferrández O, Campillo N, Horcajada J, Basas M, Lipman J, Roberts J. Plasma and cerebrospinal fluid concentrations of linezolid in neurosurgical critically ill patients with proven or suspected central nervous system infections. Int J Antimicrob Agents 2014; 44:409-15. [DOI: 10.1016/j.ijantimicag.2014.07.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/20/2014] [Accepted: 07/24/2014] [Indexed: 11/24/2022]
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41
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Continuous versus short-term infusion of cefuroxime: assessment of concept based on plasma, subcutaneous tissue, and bone pharmacokinetics in an animal model. Antimicrob Agents Chemother 2014; 59:67-75. [PMID: 25313214 DOI: 10.1128/aac.03857-14] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The relatively short half-lives of most β-lactams suggest that continuous infusion of these time-dependent antimicrobials may be favorable compared to short-term infusion. Nevertheless, only limited solid-tissue pharmacokinetic data are available to support this theory. In this study, we randomly assigned 12 pigs to receive cefuroxime as either a short-term or continuous infusion. Measurements of cefuroxime were obtained every 30 min in plasma, subcutaneous tissue, and bone. For the measurements in solid tissues, microdialysis was applied. A two-compartment population model was fitted separately to the drug concentration data for the different tissues using a nonlinear mixed-effects regression model. Estimates of the pharmacokinetic parameters and time with concentrations above the MIC were derived using Monte Carlo simulations. Except for subcutaneous tissue in the short-term infusion group, the tissue penetration was incomplete for all tissues. For short-term infusion, the tissue penetration ratios were 0.97 (95% confidence interval [CI], 0.67 to 1.39), 0.61 (95% CI, 0.51 to 0.73), and 0.45 (95% CI, 0.36 to 0.56) for subcutaneous tissue, cancellous bone, and cortical bone, respectively. For continuous infusion, they were 0.53 (95% CI, 0.33 to 0.84), 0.38 (95% CI, 0.23 to 0.57), and 0.27 (95% CI, 0.13 to 0.48) for the same tissues, respectively. The absolute areas under the concentration-time curve were also lower in the continuous infusion group. Nevertheless, a significantly longer time with concentrations above the MIC was found for continuous infusion up until MICs of 4, 2, 2, and 0.5 μg/ml for plasma and the same three tissues mentioned above, respectively. For drugs with a short half-life, like cefuroxime, continuous infusion seems to be favorable compared to short-term infusion; however, incomplete tissue penetration and high MIC strains may jeopardize the continuous infusion approach.
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Roberts JA, Abdul-Aziz MH, Lipman J, Mouton JW, Vinks AA, Felton TW, Hope WW, Farkas A, Neely MN, Schentag JJ, Drusano G, Frey OR, Theuretzbacher U, Kuti JL. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. THE LANCET. INFECTIOUS DISEASES 2014; 14:498-509. [PMID: 24768475 DOI: 10.1016/s1473-3099(14)70036-2] [Citation(s) in RCA: 660] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in suboptimum outcomes. In this Review, we explore the challenges related to patients and pathogens that contribute to inadequate antibiotic dosing and discuss how to implement a process for individualised antibiotic therapy that increases the accuracy of dosing and optimises care for critically ill patients. To improve antibiotic dosing, any physiological changes in patients that could alter antibiotic concentrations should first be established; such changes include altered fluid status, changes in serum albumin concentrations and renal and hepatic function, and microvascular failure. Second, antibiotic susceptibility of pathogens should be confirmed with microbiological techniques. Data for bacterial susceptibility could then be combined with measured data for antibiotic concentrations (when available) in clinical dosing software, which uses pharmacokinetic/pharmacodynamic derived models from critically ill patients to predict accurately the dosing needs for individual patients. Individualisation of dosing could optimise antibiotic exposure and maximise effectiveness.
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Affiliation(s)
- Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | - Mohd H Abdul-Aziz
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Johan W Mouton
- Nijmegen Medical Centre, Radboud University, Nijmegen, Netherlands
| | - Alexander A Vinks
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | | | - William W Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Andras Farkas
- Department of Pharmacy, Nyack Hospital, Nyack, NY, USA
| | - Michael N Neely
- Laboratory of Applied Pharmacokinetics, University of Southern California, Los Angeles, CA, USA
| | | | - George Drusano
- Institute for Therapeutic Innovation, College of Medicine, Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Otto R Frey
- Department of Pharmacy, Heidenheim Hospital, Heidenheim, Germany
| | | | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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Pharmacokinetics of cefuroxime in porcine cortical and cancellous bone determined by microdialysis. Antimicrob Agents Chemother 2014; 58:3200-5. [PMID: 24663019 DOI: 10.1128/aac.02438-14] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Traditionally, the pharmacokinetics of antimicrobials in bone have been investigated using bone biopsy specimens, but this approach suffers from considerable methodological limitations. Consequently, new methods are needed. The objectives of this study were to assess the feasibility of microdialysis (MD) for measuring cefuroxime in bone and to obtain pharmacokinetic profiles for the same drug in porcine cortical and cancellous bone. The measurements were conducted in bone wax sealed and unsealed drill holes in cortical bone and in drill holes in cancellous bone and in subcutaneous tissue. As a reference, the free and total plasma concentrations were also measured. The animals received a bolus of 1,500 mg cefuroxime over 30 min. No significant differences were found between the key pharmacokinetic parameters for sealed and unsealed drill holes in cortical bone. The mean ± standard error of the mean area under the concentration-time curve (AUC) values from 0 to 5 h were 6,013 ± 1,339, 3,222 ± 1086, 2,232 ± 635, and 952 ± 290 min · μg/ml for free plasma, subcutaneous tissue, cancellous bone, and cortical bone, respectively (P < 0.01, analysis of variance). The AUC for cortical bone was also significantly different from that for cancellous bone (P = 0.04). This heterogeneous tissue distribution was also reflected in other key pharmacokinetic parameters. This study validates MD as a suitable method for measuring cefuroxime in bone. Cefuroxime penetration was impaired for all tissues, and bone may not be considered one distinct compartment.
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44
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Bugs, hosts and ICU environment: countering pan-resistance in nosocomial microbiota and treating bacterial infections in the critical care setting. ACTA ACUST UNITED AC 2014; 61:e1-e19. [PMID: 24492197 DOI: 10.1016/j.redar.2013.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/04/2013] [Indexed: 02/07/2023]
Abstract
ICUs are areas where resistance problems are the largest, and these constitute a major problem for the intensivist's clinical practice. Main resistance phenotypes among nosocomial microbiota are (i) vancomycin-resistance/heteroresistance and tolerance in grampositives (MRSA, enterococci) and (ii) efflux pumps/enzymatic resistance mechanisms (ESBLs, AmpC, metallo-betalactamases) in gramnegatives. These phenotypes are found at different rates in pathogens causing respiratory (nosocomial pneumonia/ventilator-associated pneumonia), bloodstream (primary bacteremia/catheter-associated bacteremia), urinary, intraabdominal and surgical wound infections and endocarditis in the ICU. New antibiotics are available to overcome non-susceptibility in grampositives; however, accumulation of resistance traits in gramnegatives has led to multidrug resistance, a worrisome problem nowadays. This article reviews microorganism/infection risk factors for multidrug resistance, suggesting adequate empirical treatments. Drugs, patient and environmental factors all play a role in the decision to prescribe/recommend antibiotic regimens in the specific ICU patient, implying that intensivists should be familiar with available drugs, environmental epidemiology and patient factors.
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45
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Reply to "Breakthrough bacteremia by linezolid-susceptible Enterococcus faecalis under linezolid treatment in a severe polytrauma patient". Antimicrob Agents Chemother 2013; 57:6413-4. [PMID: 24222609 DOI: 10.1128/aac.01587-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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46
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Tsuji Y, Yukawa E, Hiraki Y, Matsumoto K, Mizoguchi A, Morita K, Kamimura H, Karube Y, To H. Population pharmacokinetic analysis of linezolid in low body weight patients with renal dysfunction. J Clin Pharmacol 2013; 53:967-73. [PMID: 23918457 DOI: 10.1002/jcph.133] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 06/12/2013] [Indexed: 11/09/2022]
Abstract
Linezolid has antibacterial activity against aerobic Gram-positive cocci, including methicillin-resistant Staphylococcus aureus (MRSA). Adjustment of the dose of linezolid has been proposed to be unnecessary in patients with reduced renal function. However, platelet counts and hemoglobin levels were shown to be significantly lower in such patients than in patients with normal renal function. The population pharmacokinetic (PPK) of linezolid was investigated in MRSA infected patients with renal dysfunction. Linezolid concentrations in serum were measured by high-performance liquid chromatography. PPK analysis was performed in the nonlinear mixed effects model (NONMEM) computer program. In the final PPK model, total body weight (TBW), estimated glomerular filtration rate (eGFR), hemoglobin (HB), and alanine amino transferase (ALT) were influential covariates on total body clearance (CL), and the volume of distribution (Vd) was affected by TBW, which was expressed as CL (L/h) = 0.00327 × TBW × eGFR(0.428) × HB(0.502) × 0.283 (ALT ≥ 100 IU/L) and CL (L/h) = 0.00327 × TBW × eGFR(0.428) × HB(0.502) (ALT < 100 IU/L), Vd (L) = 1.310 × TBW. The PPK parameters of linezolid obtained here are useful for the optimal use of linezolid with similar patient population characteristics.
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Affiliation(s)
- Yasuhiro Tsuji
- Department of Medical Pharmaceutics, Graduate School of Medicine and Pharmaceutical Sciences for Research, University of Toyama, Toyama, Japan.
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47
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Yagi T, Naito T, Doi M, Nagura O, Yamada T, Maekawa M, Sato S, Kawakami J. Plasma exposure of free linezolid and its ratio to minimum inhibitory concentration varies in critically ill patients. Int J Antimicrob Agents 2013; 42:329-34. [DOI: 10.1016/j.ijantimicag.2013.06.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 06/17/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
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48
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Importance of relating efficacy measures to unbound drug concentrations for anti-infective agents. Clin Microbiol Rev 2013; 26:274-88. [PMID: 23554417 DOI: 10.1128/cmr.00092-12] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
For the optimization of dosing regimens of anti-infective agents, it is imperative to have a good understanding of pharmacokinetics (PK) and pharmacodynamics (PD). Whenever possible, drug efficacy needs to be related to unbound concentrations at the site of action. For anti-infective drugs, the infection site is typically located outside plasma, and a drug must diffuse through capillary membranes to reach its target. Disease- and drug-related factors can contribute to differential tissue distribution. As a result, the assumption that the plasma concentration of drugs represents a suitable surrogate of tissue concentrations may lead to erroneous conclusions. Quantifying drug exposure in tissues represents an opportunity to relate the pharmacologically active concentrations to an observed pharmacodynamic parameter, such as the MIC. Selection of an appropriate specimen to sample and the advantages and limitations of the available sampling techniques require careful consideration. Ultimately, the goal will be to assess the appropriateness of a drug and dosing regimen for a specific pathogen and infection.
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49
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Bohnert T, Gan LS. Plasma protein binding: from discovery to development. J Pharm Sci 2013; 102:2953-94. [PMID: 23798314 DOI: 10.1002/jps.23614] [Citation(s) in RCA: 230] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 04/25/2013] [Accepted: 04/25/2013] [Indexed: 12/25/2022]
Abstract
The importance of plasma protein binding (PPB) in modulating the effective drug concentration at pharmacological target sites has been the topic of significant discussion and debate amongst drug development groups over the past few decades. Free drug theory, which states that in absence of energy-dependent processes, after steady state equilibrium has been attained, free drug concentration in plasma is equal to free drug concentration at the pharmacologic target receptor(s) in tissues, has been used to explain pharmacokinetics/pharmacodynamics relationships in a large number of cases. Any sudden increase in free concentration of a drug could potentially cause toxicity and may need dose adjustment. Free drug concentration is also helpful to estimate the effective concentration of drugs that potentially can precipitate metabolism (or transporter)-related drug-drug interactions. Disease models are extensively validated in animals to progress a compound into development. Unbound drug concentration, and therefore PPB information across species is very informative in establishing safety margins and guiding selection of First in Human (FIH) dose and human efficacious dose. The scope of this review is to give an overview of reported role of PPB in several therapeutic areas, highlight cases where PPB changes are clinically relevant, and provide drug metabolism and pharmacokinetics recommendations in discovery and development settings.
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Affiliation(s)
- Tonika Bohnert
- Preclinical PK & In Vitro ADME, Biogen Idec Inc., Cambridge, Massachusetts 02142, USA.
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50
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Grgurich PE, Hudcova J, Lei Y, Sarwar A, Craven DE. Management and prevention of ventilator-associated pneumonia caused by multidrug-resistant pathogens. Expert Rev Respir Med 2013; 6:533-55. [PMID: 23134248 DOI: 10.1586/ers.12.45] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Ventilator-associated pneumonia (VAP) due to multidrug-resistant (MDR) pathogens is a leading healthcare-associated infection in mechanically ventilated patients. The incidence of VAP due to MDR pathogens has increased significantly in the last decade. Risk factors for VAP due to MDR organisms include advanced age, immunosuppression, broad-spectrum antibiotic exposure, increased severity of illness, previous hospitalization or residence in a chronic care facility and prolonged duration of invasive mechanical ventilation. Methicillin-resistant Staphylococcus aureus and several different species of Gram-negative bacteria can cause MDR VAP. Especially difficult Gram-negative bacteria include Pseudomonas aeruginosa, Acinetobacter baumannii, carbapenemase-producing Enterobacteraciae and extended-spectrum β-lactamase producing bacteria. Proper management includes selecting appropriate antibiotics, optimizing dosing and using timely de-escalation based on antiimicrobial sensitivity data. Evidence-based strategies to prevent VAP that incorporate multidisciplinary staff education and collaboration are essential to reduce the burden of this disease and associated healthcare costs.
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Affiliation(s)
- Philip E Grgurich
- Department of Pharmacy, Lahey Clinic Medical Center, Burlington, MA 01805, USA
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