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de Maat MMR, van Leeuwen HJ, Roovers L, Ahlers SJGM, Lambers J, Hovens MMC. Large variation in anti-factor Xa levels with nadroparin as thromboprophylaxis in COVID-19 and non-COVID-19 critically ill patients. BMC Pharmacol Toxicol 2024; 25:16. [PMID: 38321487 PMCID: PMC10848501 DOI: 10.1186/s40360-024-00733-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/12/2024] [Indexed: 02/08/2024] Open
Abstract
PURPOSE Critically ill COVID-19 and non-COVID-19 patients receive thromboprophylaxis with the LMWH nadroparin. Whether a standard dosage is adequate in attaining the target anti-FXa levels (0.20-0.50 IU/ml) in these groups is unknown. METHODS This study was a prospective, observational study in the ICU of a large general teaching hospital in the Netherlands. COVID-19 and non-COVID-19 patients admitted to the ICU who received LMWH in a prophylactic dosage of 2850 IU, 5700 IU or 11400 IU subcutaneously were eligible for the study. Anti-FXa levels were determined 4 h after administration. Relevant laboratory parameters, prespecified co-variates and clinical data were extracted from the electronic health record system. The primary goal was to evaluate anti-FXa levels in critically ill patients on a prophylactic dosage of nadroparin. The second goal was to investigate whether covariates had an influence on anti-FXa levels. RESULTS A total of 62 patients were included in the analysis. In the COVID-19 group and non-COVID-19 group, 29 (96%) and 12 patients (38%) reached anti-FXa levels above 0.20 IU/ml, respectively. In the non-COVID-19 group, 63% of the patients had anti-FXA levels below the target range. When adjusted for nadroparin dosage a significant relation was found between body weight and the anti-FXa level (p = 0.013). CONCLUSION A standard nadroparin dosage of 2850 IU sc in the critically ill patient is not sufficient to attain target anti-FXa levels in the majority of the studied patient group. We suggest a standard higher dosage in combination with body-weight dependent dosing as it leads to better exposure to nadroparin. CLINICAL TRIALS REGISTRATION Retrospectively registered, ClinicalTrials.gov ID NTC 05926518 g, date of registration 06/01/23, unique ID 2020/1725.
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Affiliation(s)
- Monique M R de Maat
- Department of Clinical Pharmacy, Rijnstate Hospital, Arnhem, The Netherlands.
| | - Henk J van Leeuwen
- Department of Internal Medicine and Intensive Care, Rijnstate Hospital, Arnhem, The Netherlands
| | - Lian Roovers
- Department of Epidemiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Sabine J G M Ahlers
- Department of Clinical Pharmacy, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jolanda Lambers
- Department of Clinical Chemistry and Hematology Laboratory, Rijnstate Hospital, Arnhem, The Netherlands
| | - Marcel M C Hovens
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
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Janssens PMW, Pot MW, Wouters M, Leeuwen HJV, Borren MMGJV. What extreme laboratory values can be obtained that (some) patients can survive with? Scandinavian Journal of Clinical and Laboratory Investigation 2021; 82:50-57. [DOI: 10.1080/00365513.2021.2015800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Pim M. W. Janssens
- Department of Clinical Chemistry and Haematology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Michiel W. Pot
- Department of Clinical Chemistry and Haematology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Moniek Wouters
- Physician in Training for Specialist Physician Pulmonary Diseases, Department of Pulmonary Diseases, Rijnstate Hospital, Arnhem, The Netherlands
| | - Henk J. van Leeuwen
- Physician Internal Medicine, Registered Intensive Care Specialist, Department of Intensive Care, Rijnstate Hospital, Arnhem, The Netherlands
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Stolk RF, van Leeuwen HJ, Kox M, van Borren M, de Boer H, Pickkers P. The chicken or the egg: low testosterone predisposes for COVID-19 or COVID-19 induces a decrease in testosterone? Crit Care 2021; 25:237. [PMID: 34233744 PMCID: PMC8261810 DOI: 10.1186/s13054-021-03664-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 06/30/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Roeland F Stolk
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Centre for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk J van Leeuwen
- Department of Intensive Care Medicine, Hospital Rijnstate, Arnhem, The Netherlands.,Department of Internal Medicine, Hospital Rijnstate, Arnhem, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Centre for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel van Borren
- Department of Laboratory Medicine, Hospital Rijnstate, Arnhem, The Netherlands
| | - Hans de Boer
- Department of Internal Medicine, Hospital Rijnstate, Arnhem, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands. .,Radboud Centre for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
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Stolk RF, Naumann F, van der Pasch E, Schouwstra J, Bressers S, van Herwaarden AE, Gerretsen J, Schambergen R, Ruth M, van der Hoeven HG, van Leeuwen HJ, Pickkers P, Kox M. Phenylephrine impairs host defence mechanisms to infection: a combined laboratory study in mice and translational human study. Br J Anaesth 2021; 126:652-664. [PMID: 33483132 DOI: 10.1016/j.bja.2020.11.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/20/2020] [Accepted: 11/20/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Immunosuppression after surgery is associated with postoperative complications, mediated in part by catecholamines that exert anti-inflammatory effects via the β-adrenergic receptor. Phenylephrine, generally regarded as a selective α-adrenergic agonist, is frequently used to treat perioperative hypotension. However, phenylephrine may impair host defence through β-adrenergic affinity. METHODS Human leukocytes were stimulated with lipopolysaccharide (LPS) in the presence or absence of phenylephrine and α- and β-adrenergic antagonists. C57BL/6J male mice received continuous infusion of phenylephrine (30-50 μg kg-1 min-1 i.v.) or saline via micro-osmotic pumps, before LPS administration (5 mg kg-1 i.v.) or caecal ligation and puncture (CLP). Twenty healthy males were randomised to a 5 h infusion of phenylephrine (0.5 μg kg-1 min-1) or saline before receiving LPS (2 ng kg-1 i.v.). RESULTS In vitro, phenylephrine enhanced LPS-induced production of the anti-inflammatory cytokine interleukin (IL)-10 (maximum augmentation of 93%) while attenuating the release of pro-inflammatory mediators. These effects were reversed by pre-incubation with β-antagonists, but not α-antagonists. Plasma IL-10 levels were higher in LPS-challenged mice infused with phenylephrine, whereas pro-inflammatory mediators were reduced. Phenylephrine infusion increased bacterial counts after CLP in peritoneal fluid (+42%, P=0.0069), spleen (+59%, P=0.04), and liver (+35%, P=0.09). In healthy volunteers, phenylephrine enhanced the LPS-induced IL-10 response (+76%, P=0.0008) while attenuating plasma concentrations of pro-inflammatory mediators including IL-8 (-15%, P=0.03). CONCLUSIONS Phenylephrine exerts potent anti-inflammatory effects, possibly involving the β-adrenoreceptor. Phenylephrine promotes bacterial outgrowth after surgical peritonitis. Phenylephrine may therefore compromise host defence in surgical patients and increase susceptibility towards infection. CLINICAL TRIAL REGISTRATION NCT02675868 (Clinicaltrials.gov).
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Affiliation(s)
- Roeland F Stolk
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Intensive Care Medicine, Hospital Rijnstate, Arnhem, The Netherlands
| | - Flavia Naumann
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva van der Pasch
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost Schouwstra
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Steffi Bressers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jelle Gerretsen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roel Schambergen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mike Ruth
- Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hans G van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henk J van Leeuwen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Intensive Care Medicine, Hospital Rijnstate, Arnhem, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands.
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Martial LC, Ter Heine R, Schouten JA, Hunfeld NG, van Leeuwen HJ, Verweij PE, de Lange DW, Pickkers P, Brüggemann RJ. Population Pharmacokinetic Model and Pharmacokinetic Target Attainment of Micafungin in Intensive Care Unit Patients. Clin Pharmacokinet 2017; 56:1197-1206. [PMID: 28144840 PMCID: PMC5591795 DOI: 10.1007/s40262-017-0509-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To study the pharmacokinetics of micafungin in intensive care patients and assess pharmacokinetic (PK) target attainment for various dosing strategies. METHODS Micafungin PK data from 20 intensive care unit patients were available. A population-PK model was developed. Various dosing regimens were simulated: licensed regimens (I) 100 mg daily; (II) 100 mg daily with 200 mg from day 5; and adapted regimens 200 mg on day 1 followed by (III) 100 mg daily; (IV) 150 mg daily; and (V) 200 mg daily. Target attainment based on a clinical PK target for Candida as well as non-Candida parapsilosis infections was assessed for relevant minimum inhibitory concentrations [MICs] (Clinical and Laboratory Standards Institute). Parameter uncertainty was taken into account in simulations. RESULTS A two-compartment model best fitted the data. Clearance was 1.10 (root square error 8%) L/h and V 1 and V 2 were 17.6 (root square error 14%) and 3.63 (root square error 8%) L, respectively. Median area under the concentration-time curve over 24 h (interquartile range) on day 14 for regimens I-V were 91 (67-122), 183 (135-244), 91 (67-122), 137 (101-183) and 183 (135-244) mg h/L, respectively, for a typical patient of 70 kg. For the MIC/area under the concentration-time curve >3000 target (all Candida spp.), PK target attainment was >91% on day 14 (MIC 0.016 mg/L epidemiological cut-off) for all of the dosing regimens but decreased to (I) 44%, (II) 91%, (III) 44%, (IV) 78% and (V) 91% for MIC 0.032 mg/L. For the MIC/area under the concentration-time curve >5000 target (non-C. parapsilosis spp.), PK target attainment varied between 62 and 96% on day 14 for MIC 0.016. CONCLUSIONS The licensed micafungin maintenance dose results in adequate exposure based on our simulations with a clinical PK target for Candida infections but only 62% of patients reach the target for non-C. parapsilosis. In the case of pathogens with an attenuated micafungin MIC, patients may benefit from dose escalation to 200 mg daily. This encourages future study.
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Affiliation(s)
- Lisa C Martial
- Department of Pharmacy, Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6525 HB, The Netherlands
- The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Center of Expertise in Mycology, Radboud University Medical Center/CWZ, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6525 HB, The Netherlands
- The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Nicole G Hunfeld
- Department of Intensive Care and Pharmacy, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Henk J van Leeuwen
- Department of Intensive Care, Rijnstate Hospital, Arnhem, The Netherlands
| | - Paul E Verweij
- The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Center of Expertise in Mycology, Radboud University Medical Center/CWZ, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6525 HB, The Netherlands.
- The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
- Center of Expertise in Mycology, Radboud University Medical Center/CWZ, Nijmegen, The Netherlands.
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Martial LC, Brüggemann RJM, Schouten JA, van Leeuwen HJ, van Zanten AR, de Lange DW, Muilwijk EW, Verweij PE, Burger DM, Aarnoutse RE, Pickkers P, Dorlo TPC. Dose Reduction of Caspofungin in Intensive Care Unit Patients with Child Pugh B Will Result in Suboptimal Exposure. Clin Pharmacokinet 2017; 55:723-33. [PMID: 26649870 PMCID: PMC4875935 DOI: 10.1007/s40262-015-0347-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background and Objectives Caspofungin is an echinocandin antifungal agent used as first-line therapy for the treatment of invasive candidiasis. The maintenance dose is adapted to body weight (BW) or liver function (Child-Pugh score B or C). We aimed to study the
pharmacokinetics of caspofungin and assess pharmacokinetic target attainment for various dosing strategies. Methods Caspofungin pharmacokinetic data from 21 intensive care unit (ICU) patients was available. A population pharmacokinetic model was developed. Various dosing regimens (loading dose/maintenance dose) were simulated: licensed regimens (I) 70/50 mg (for BW <80 kg) or 70/70 mg (for BW >80 kg); and (II) 70/35 mg (for Child-Pugh score B); and adapted regimens (III) 100/50 mg (for Child-Pugh score B); (IV) 100/70 mg; and (V) 100/100 mg. Target attainment based on a preclinical pharmacokinetic target for Candida albicans was assessed for relevant minimal inhibitory concentrations (MICs). Results A two-compartment model best fitted the data. Clearance was 0.55 L/h and the apparent volumes of distribution in the central and peripheral compartments were 8.9 and 5.0 L, respectively. The median area under the plasma concentration–time curve from time zero to 24 h on day 14 for regimens I–V were 105, 65, 93, 130, and 186 mg·h/L, respectively. Pharmacokinetic target attainment was 100 % (MIC 0.03 µg/mL) irrespective of dosing regimen but decreased to (I) 47 %, (II) 14 %, (III) 36 %, (IV) 69 %, and (V) 94 % for MIC 0.125 µg/mL. Conclusion The caspofungin maintenance dose should not be reduced in non-cirrhotic ICU patients based on the Child-Pugh score if this classification is driven by hypoalbuminemia as it results in significantly lower exposure. A higher maintenance dose of 70 mg in ICU patients results in target attainment of >90 % of the ICU patients with species with an MIC of up to 0.125 µg/mL.
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Affiliation(s)
- Lisa C Martial
- Department of Pharmacy, Radboud university medical center, P.O. Box 9101, 6525 HB, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Radboud university medical center, P.O. Box 9101, 6525 HB, Nijmegen, The Netherlands. .,Radboud Institute for Health Sciences, Nijmegen, The Netherlands.
| | - Jeroen A Schouten
- Department of Intensive Care, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Henk J van Leeuwen
- Department of Intensive Care, Rijnstate Hospital, Arnhem, The Netherlands
| | - Arthur R van Zanten
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Dylan W de Lange
- Department of Intensive Care and National Poison Information Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eline W Muilwijk
- Department of Pharmacy, Radboud university medical center, P.O. Box 9101, 6525 HB, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul E Verweij
- Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Department of Medical Microbiology, Radboud university medical center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud university medical center, P.O. Box 9101, 6525 HB, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud university medical center, P.O. Box 9101, 6525 HB, Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.,Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
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Lempers VJ, Schouten JA, Hunfeld NG, Colbers A, van Leeuwen HJ, Burger DM, Verweij PE, Pickkers P, Brüggemann RJ. Altered Micafungin Pharmacokinetics in Intensive Care Unit Patients. Antimicrob Agents Chemother 2015; 59:4403-9. [PMID: 25963988 PMCID: PMC4505244 DOI: 10.1128/aac.00623-15] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 05/06/2015] [Indexed: 11/20/2022] Open
Abstract
Micafungin is considered an important agent for the treatment of invasive fungal infections in the intensive care unit (ICU). Little is known on the pharmacokinetics of micafungin. We investigated micafungin pharmacokinetics (PK) in ICU patients and set out to explore the parameters that influence micafungin plasma concentrations. ICU patients receiving 100 mg of intravenous micafungin once daily for suspected or proven fungal infection or as prophylaxis were eligible. Daily trough concentrations and PK curves (days 3 and 7) were collected. Pharmacokinetic analysis was performed using a standard two-stage approach. Twenty patients from the ICUs of four hospitals were evaluated. On day 3 (n = 20), the median (interquartile range [IQR]) area under the concentration-time curve from 0 to 24 h (AUC0-24) was 78.6 (65.3 to 94.1) mg · h/liter, the maximum concentration of drug in serum (Cmax) was 7.2 (5.4 to 9.2) mg/liter, the concentration 24 h after dosing (C24) was 1.55 (1.4 to 3.1) mg/liter, the volume of distribution (V) was 25.6 (21.3 to 29.1) liters, the clearance (CL) was 1.3 (1.1 to 1.5) liters/h, and the elimination half-life (t1/2) was 13.7 (12.2 to 15.5) h. The pharmacokinetic parameters on day 7 (n = 12) were not significantly different from those on day 3. Daily trough concentrations (day 3 to the end of therapy) showed moderate interindividual (57.9%) and limited intraindividual variability (12.9%). No covariates of the influence on micafungin exposure were identified. Micafungin was considered safe and well tolerated. We performed the first PK study with very intensive sampling on multiple occasions in ICU patients, which aided in resolving micafungin PK. Strikingly, micafungin exposure in our cohort of ICU patients was lower than that in healthy volunteers but not significantly different from that of other reference populations. The clinical consequence of these findings must be investigated in a pharmacokinetic-pharmacodynamic (PK-PD) study incorporating outcome in a larger cohort. (This study is registered at ClinicalTrials.gov under registration no. NCT01783379.).
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Affiliation(s)
- Vincent J Lempers
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Canisius Wilhelmina Hospital, Department of Intensive Care, Nijmegen, The Netherlands
| | - Nicole G Hunfeld
- Erasmus Medical Center, Department of Intensive Care, Rotterdam, The Netherlands
| | - Angela Colbers
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Henk J van Leeuwen
- Rijnstate Hospital, Department of Intensive Care, Arnhem, The Netherlands
| | - David M Burger
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Paul E Verweij
- Radboud Institute for Health Sciences, Nijmegen, The Netherlands Radboud University Medical Center, Department of Medical Microbiology, Nijmegen, The Netherlands
| | - Peter Pickkers
- Radboud University Medical Center, Department of Intensive Care, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Mulkens CE, van Lochem EG, Folman CC, van der Spek E, van Leeuwen HJ. [Ceftriaxone-induced immune haemolytic anaemia and multi-organ failure]. Ned Tijdschr Geneeskd 2015; 159:A8054. [PMID: 25714764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Drug-induced immune haemolytic anaemia (DIIHA) is caused by various drugs or their metabolites. Cephalosporins are associated with haemolytic anaemia but multi-organ failure is rarely described. CASE DESCRIPTION We report the case of a 57-year-old female who was diagnosed with neuroborreliosis and treated with ceftriaxone. The patient developed severe DIIHA. Massive intravascular haemolysis led to shock and acute renal failure, necessitating mechanical ventilation and dialysis. Treatment with ceftriaxone was discontinued and glucocorticoids were prescribed. The patient recovered slowly but fully. CONCLUSION Ceftriaxone-induced immune haemolytic anaemia is a rare but potentially fatal condition.
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Affiliation(s)
- Chantal E Mulkens
- Radboudumc, afd. Anesthesiologie, Pijn- en Palliatieve Geneeskunde, Nijmegen
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de Maat MMR, van Leeuwen HJ, Edelbroek PM. High unbound fraction of valproic acid in a hypoalbuminemic critically ill patient on renal replacement therapy. Ann Pharmacother 2011; 45:e18. [PMID: 21325101 DOI: 10.1345/aph.1p308] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe a hypoalbuminemic critically ill patient with subtherapeutic total valproic acid serum concentrations but unbound valproic acid concentrations within normal limits. CASE SUMMARY During an intensive care unit admission, a 61-year-old woman with urosepsis and multiorgan dysfunction syndrome developed tonic-clonic seizures with respiratory failure, and tracheal intubation was performed. An intravenous loading dose of valproic acid 1500 mg (25 mg/kg) was administered and therapy was continued with valproic acid 750 mg (12.5 mg/kg) twice daily. Because of progressive renal failure, continuous venovenous hemofiltration was started on day 3 of valproic acid therapy. On day 7 of valproic acid therapy, routine testing of serum valproic acid trough concentration returned as undetectable. Subsequent determinations of trough serum concentrations of total valproic acid showed values below the therapeutic range. Data from a full pharmacokinetic curve (multiple blood samples during a dosing interval) showed that the free fraction of valproic acid was >60%. Although total valproic acid concentrations were still low, the unbound concentrations were considered therapeutic. Serum albumin was 1.2 g/dL on the multiple sampling day. DISCUSSION The patient's hypoalbuminemia probably explains the remarkably high free fraction of valproic acid. Our hypothesis is that the low albumin level was associated with high plasma clearance of valproic acid, leading to extremely low total drug concentrations. To our knowledge, this high percentage of free valproic acid has not been previously described. CONCLUSIONS Health-care professionals should be aware of the need of early determination of both total and free fraction valproic acid serum concentrations in hypoalbuminemic critically ill patients. Increasing the dose of valproic acid purely based on total valproic acid serum concentrations in this patient population should be avoided.
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Schurink CAM, Visscher S, Lucas PJF, van Leeuwen HJ, Buskens E, Hoff RG, Hoepelman AIM, Bonten MJM. A Bayesian decision-support system for diagnosing ventilator-associated pneumonia. Intensive Care Med 2007; 33:1379-86. [PMID: 17572880 DOI: 10.1007/s00134-007-0728-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 05/08/2007] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine the diagnostic performance of a Bayesian Decision-Support System (BDSS) for ventilator-associated pneumonia (VAP). DESIGN A previously developed BDSS, automatically obtaining patient data from patient information systems, provides likelihood predictions of VAP. In a prospectively studied cohort of 872 ICU patients, VAP was diagnosed by two infectious-disease specialists using a decision tree (reference diagnosis). After internal validation daily BDSS predictions were compared with the reference diagnosis. For data analysis two approaches were pursued: using BDSS predictions (a) for all 9422 patient days, and (b) only for the 238 days with presumed respiratory tract infections (RTI) according to the responsible physicians. MEASUREMENTS AND RESULTS 157 (66%) of 238 days with presumed RTI fulfilled criteria for VAP. In approach (a), median daily BDSS likelihood predictions for days with and without VAP were 77% [Interquartile range (IQR) = 56-91%] and 14% [IQR 5-42%, p < 0.001, Mann-Whitney U-test (MWU)], respectively. In receiver operating characteristics (ROC) analysis, optimal BDSS cut-off point for VAP was 46%, and with this cut-off point positive predictive value (PPV) and negative predictive value (NPV) were 6.1 and 99.6%, respectively [AUC = 0.857 (95% CI 0.827-0.888)]. In approach (b), optimal cut-off for VAP was 78%, and with this cut-off point PPV and NPV were 86 and 66%, respectively [AUC = 0.846 (95% CI 0.794-0.899)]. CONCLUSIONS As compared with the reference diagnosis, the BDSS had good test characteristics for diagnosing VAP, and might become a useful tool for assisting ICU physicians, both for routinely daily assessment and in patients clinically suspected of having VAP. Empirical validation of its performance is now warranted.
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Affiliation(s)
- Carolina A M Schurink
- University Medical Center Utrecht, Division of Internal Medicine, Geriatrics and Infectious Diseases, Heidelberglaan 100, HP F.02.126, 3584 CX, Utrecht, The Netherlands
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Abstract
Vascular endothelial growth factor (VEGF) is a potent vascular permeability factor. The development of capillary leak is common in septic patients, and several sepsis-associated mediators may induce VEGF production. The potential role of VEGF during sepsis has not been studied to date. The aim of the study was first to assess whether circulating VEGF levels increase during sepsis, and second, to examine whether plasma VEGF levels are associated with disease severity. VEGF levels were measured in serial plasma samples of 18 patients with severe sepsis and in 40 healthy controls. VEGF levels were correlated to clinical signs and symptoms. VEGF levels were significantly elevated in sepsis patients compared with healthy controls (134 vs. 55 pg/mL; P <0.001). Serum albumin levels used as an indirect measure of vascular leak were decreased in septic patients. Increased plasma VEGF levels at study entry were correlated to severity of multiple organ dysfunction during the course of disease (Pearson correlation coefficient r=0.75; P=0.001). Moreover, maximum VEGF levels in nonsurvivors were significantly higher than those in survivors (P=0.018). These data show that plasma VEGF levels are elevated during severe sepsis. Furthermore, our data indicate that plasma VEGF levels are associated with disease severity and mortality. Further study of the potential role of VEGF in the development of sepsis-associated capillary leak is indicated.
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Affiliation(s)
- Michiel van der Flier
- Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands.
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13
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Abstract
OBJECTIVE Lipoproteins have been implicated to play a role in innate immunity. Changes in lipoprotein levels have been reported in a variety of inflammatory disorders. Not much is known about lipoprotein metabolism in patients with severe sepsis. We conducted an ancillary study in a multiple-center phase III sepsis trial to investigate the dynamics of plasma lipoproteins in patients with severe sepsis. DESIGN Prospective analysis in patients meeting criteria for severe sepsis as part of a multiple-center sepsis study (KyberSept) with antithrombin III (Kybernin P). SETTING University hospital intensive care unit. PATIENTS Seventeen patients were included in the study. INTERVENTIONS Randomized patients received a loading dose of 6000 IU of antithrombin III (Kybernin P) or placebo followed by a 96-hr continuous infusion of 250 IU/hr antithrombin III (Kybernin P) or placebo. In each patient, serial blood samples for total cholesterol, lipoprotein cholesterol, triglycerides, apolipoprotein A-1, apolipoprotein B, and C-reactive protein determination as well as clinical data were collected over 28 days. MEASUREMENTS AND MAIN RESULTS Plasma cholesterol levels rapidly decreased from 2.67 +/- 2.02 mmol/L on day 0 to a nadir of 1.41 +/- 0.70 mmol/L on day 3, followed by a slow increase to 4.18 +/- 1.94 mmol/L on day 28. High-density lipoprotein (HDL) cholesterol concentrations decreased rapidly from 0.84 +/- 0.92 mmol/L to a nadir of 0.42 +/- 0.35 mmol/L on day 3, to show a slow increase during the following 4 wks to 0.84 +/- 0.42 mmol/L. The low-density lipoprotein (LDL) cholesterol concentrations were already low (0.94 +/- 0.81 mmol/L) at study entry, to show a progressive increase to subnormal values (2.01 +/- 0.94 mmol/L) at 4 wks. Nadir and recovery lipoprotein concentrations were significantly different (paired Student's t-test, p <.05). A significant correlation was found between HDL cholesterol and apolipoprotein A-1 (r =.714, p <.05) and between LDL cholesterol and apolipoprotein B (r =.733, p <.05). There was no statistical difference in lipoprotein concentrations either between survivors and nonsurvivors or between patients receiving antithrombin III or placebo. Serum amyloid A was a major apoprotein (45%) in HDL at the start of the sepsis and was slowly replaced by apolipoprotein A-1 during recovery. A positive correlation was found between plasma C-reactive protein concentrations and serum amyloid A concentrations in HDL (r =.684, p <.05). No other relevant correlations were found between inflammatory and lipoprotein parameters. CONCLUSIONS In patients with severe sepsis, lipoprotein concentrations rapidly change and can be reduced to 50% of recovery concentrations. The pattern of early rapid decline is found primarily in the HDL and a slow recovery in both HDL and LDL fractions. The correlation between apolipoprotein and lipoprotein cholesterol concentrations suggests a decline in lipoprotein particles. During severe sepsis, HDL is shifted to acute phase HDL, which is enriched in serum amyloid A and depleted of cholesterol and apolipoprotein A-1. Lipoprotein concentrations are unable to discriminate between survivors and nonsurvivors.
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Affiliation(s)
- Henk J van Leeuwen
- Department of Intensive Care and Clinical Toxicology, University Medical Center, Utrecht, The Netherlands
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Bonten MJM, Joore HCA, de Jongh BM, Kluytmans J, Kuijper EJ, van Leeuwen HJ, de Smet AMGA, Vandenbroucke-Grauls C. Selective decontamination of the digestive tract: all questions answered? Crit Care 2003; 7:203-5. [PMID: 12793864 PMCID: PMC270668 DOI: 10.1186/cc1881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Although many studies have shown beneficial effects of SDD on the incidence of respiratory tract infections, SDD did not become routine practice because mortality reduction was not demonstrated in individual trials, beneficial effects on duration of ventilation, ICU stay or hospital stay were not demonstrated, cost-efficacy had not been demonstrated, and selection of antibiotic resistance was considered a serious side-effect. A recent study has now shown improved patient survival and lower prevalence of antibiotic resistance in patients receiving SDD. Why could this study show mortality reduction, where all others studies had failed before? And do the microbiological data unequivocally prove protective effects of SDD on emergence of antibiotic resistance? Interestingly, the reported mortality reductions exceeds even the most optimistic predictions from previous meta-analyses, but a clear explanation is not yet evident. The data on antibiotic resistance, however, are rather superficial and do not allow to interpret the underlying epidemiological dynamics. Therefore, the recent findings are provocative and shed new light on the SDD issue, warranting studies confirming its beneficial effects but also addressing several important aspects related to study design.
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Affiliation(s)
- Marc J M Bonten
- Department of Internal Medicine & Dermatology, Division of Acute Internal Medicine & Infectious Diseases, University Medical Center Utrecht, The Netherlands.
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