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El Hassani M, Liebchen U, Marsot A. Does Sample Size, Sampling Strategy, or Handling of Concentrations Below the Lower Limit of Quantification Matter When Externally Evaluating Population Pharmacokinetic Models? Eur J Drug Metab Pharmacokinet 2024:10.1007/s13318-024-00897-1. [PMID: 38705941 DOI: 10.1007/s13318-024-00897-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND AND OBJECTIVES Precision dosing requires selecting the appropriate population pharmacokinetic model, which can be assessed through external evaluations (EEs). The lack of understanding of how different study design factors influence EE study outcomes makes it challenging to select the most suitable model for clinical use. This study aimed to evaluate the impact of sample size, sampling strategy, and handling of concentrations below the lower limit of quantification (BLQ) on the outcomes of EE for four population pharmacokinetic models using vancomycin and tobramycin as examples. METHODS Three virtual patient populations undergoing vancomycin or tobramycin therapy were simulated with varying sample size and sampling scenarios. The three approaches used to handle BLQ data were to (1) discard them, (2) impute them as LLOQ/2, or (3) use a likelihood-based approach. EEs were performed with NONMEM and R. RESULTS Sample size did not have an important impact on the EE results for a given scenario. Increasing the number of samples per patient did not improve predictive performance for two out of the three evaluated models. Evaluating a model developed with rich sampling did not result in better performance than those developed with regular therapeutic drug monitoring. A likelihood-based method to handle BLQ samples impacted the outcomes of the EE with lower bias for predicted troughs. CONCLUSIONS This study suggests that a large sample size may not be necessary for an EE study, and models selected based on TDM may be more generalizable. The study highlights the need for guidelines for EE of population pharmacokinetic models for clinical use.
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Affiliation(s)
- Mehdi El Hassani
- Faculté de pharmacie, Université de Montréal, 2940 chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada.
- Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada.
| | - Uwe Liebchen
- Department of Anaesthesiology, LMU University Hospital, LMU Munich, 81377, Munich, Germany
| | - Amélie Marsot
- Faculté de pharmacie, Université de Montréal, 2940 chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada
- Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de pharmacie, Université de Montréal, Montreal, QC, Canada
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Greppmair S, Liebchen U. [Treatment of sepsis on the pulse of time : Proven standards and current trends]. Anaesthesiologie 2024; 73:1-3. [PMID: 38226994 DOI: 10.1007/s00101-023-01366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Sebastian Greppmair
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, München, Deutschland
| | - Uwe Liebchen
- Klinik für Anaesthesiologie, LMU Klinikum, LMU München, Marchioninistr. 15, 81377, München, Deutschland.
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Gräfe C, Weidhase L, Liebchen U, Weigand MA, Scharf C. [Hemoperfusion in anesthesia and intensive care medicine: benefits, risks, and evidence for different systems]. Anaesthesiologie 2023; 72:843-851. [PMID: 37707564 DOI: 10.1007/s00101-023-01341-w] [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] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Hemoperfusion is a technique for the extracorporeal elimination of endogenous and exogenous toxins and harmful mediators by adsorption. It can be used as a stand-alone device, as part of a heart-lung machine or extracorporeal membrane oxygenation (ECMO) or, as is currently the case, integrated into a kidney replacement procedure. In the meantime, various suppliers offer devices with different technologies. OBJECTIVE The aim of this work was to evaluate the benefits, risks and evidence of the different systems, how they work and for which indications they are approved in Germany. METHOD To achieve this goal, a narrative assessment of the existing literature and guidelines for different indications was performed. The focus was on in vivo studies. RESULTS In principle, a distinction must be made in adsorption techniques between pure adsorption and the combination as adsorption and kidney replacement therapy. The adsorbers available in Germany include Cytosorb®, HA-330, Seraph®-100 and Toraymyxin. Combined procedures (adsorption and kidney replacement) are offered with coupled plasma filtration and adsorption (CPFA) and oXiris®. Most adsorbers have been developed for cytokine and endotoxin removal in patients with sepsis; however, to date, no randomized controlled trial (RCT) has demonstrated a survival benefit when using hemoperfusion. Therefore, the S3 guidelines for treatment of sepsis and the surviving sepsis campaign guidelines advise against its routine use. When the corona pandemic began, hemoperfusion was considered as a promising therapeutic approach. Cytosorb®, Seraph®-100, and oXiris® received emergency approval by the FDA to be used in critically ill patients with COVID-19, so questions arose about the appropriateness and importance of its use; however, the data generated did not show positive results, so its use cannot be recommended routinely either. In addition, they are not mentioned as a treatment option in the current guidelines. The use of adsorption procedures in patients with liver failure and rhabdomyolysis has only been rudimentarily studied, so any evidence is currently lacking. The only adsorber that has CE approval in Germany for both applications is Cytosorb®. In the next few years, studies will have to follow that investigate the efficacy and thus either justify or refute the use in clinical routine. Hemoperfusion procedures are used in the heart-lung machine as part of cardiac surgery for either cytokine or anticoagulant adsorption. No congruent data are available to support the use for the elimination of cytokines. If emergency cardiac surgery is required in a patient with pre-existing anticoagulation, hemoperfusion procedures can be used to prevent bleeding complications. Cytosorb® has CE approval for this indication. All available techniques are nonselective adsorption processes, so that adsorption of known and unknown substances can occur. Unintentional adsorption of drugs, such as various anti-infective agents is a relevant risk, especially when used in patients with sepsis. DISCUSSION Various adsorption systems can eliminate different known and unknown substances. Currently, there is a lack of evidence for all indications and systems to justify their routine use except in clinical trials. Future clinical trials should evaluate the potential benefits but also dangers, so that in the meantime the routine use can be justified or a recommendation against the use can be given.
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Affiliation(s)
- Caroline Gräfe
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Lorenz Weidhase
- Interdisziplinäre internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Uwe Liebchen
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christina Scharf
- Klinik für Anaesthesiologie, LMU Klinikum München, Marchioninistr. 15, 81377, München, Deutschland.
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Greimel A, Habler K, Gräfe C, Maciuga N, Brozat CI, Vogeser M, Zoller M, Happich FL, Liebchen U, Frank S, Paal M, Scharf C. Extracorporeal adsorption of protective and toxic bile acids and bilirubin in patients with cholestatic liver dysfunction: a prospective study. Ann Intensive Care 2023; 13:110. [PMID: 37943350 PMCID: PMC10635921 DOI: 10.1186/s13613-023-01198-7] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/27/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND The release of toxic bile acids (BAs) in the blood of critically ill patients with cholestatic liver dysfunction might lead to the damage of various organs. Their extracorporeal elimination using the cytokine adsorber Cytosorb® (CS) (adsorption of especially hydrophobic molecules < 60 kDa) might be promising, but data proving a potential adsorption are missing so far. METHODS The prospective Cyto-SOVLE study (NCT04913298) included 20 intensive care patients with cholestatic liver dysfunction, continuous kidney replacement therapy, total bilirubin concentration > 10 mg/dl and the application of CS into the dialysis circuit. Bilirubin and different BAs were measured pre- and post-CS at defined timepoints (10 min, 1, 3, 6, and 12 h after initiation). Relative reduction (RR, %) was calculated with: [Formula: see text]. RESULTS The median RR for total and conjugated bilirubin after initiation was - 31.8% and - 30.3%, respectively, and decreased to - 4.5% and - 4.8% after 6 h. A high initial RR was observed for the toxic BAs GCA (- 97.4%), TCA (- 94.9%), GCDCA (- 82.5%), and TCDCA (- 86.0%), decreasing after 6 h to - 32.9%, - 32.7%, - 12.8%, and - 14.3%, respectively. The protective hydrophilic BAs showed a comparable RR after initiation (UDCA: - 77.7%, GUDCA: - 83.0%, TUDCA: - 91.3%) dropping after 6 h to - 7.4%, - 8.5%, and - 12.5%, respectively. CONCLUSIONS Cytosorb® can adsorb bilirubin and toxic as well as protective BAs. However, a fast saturation of the adsorber resulting in a rapid decrease of the RR was observed. Furthermore, no relevant difference between hydrophobic toxic and hydrophilic protective BAs was detected regarding the adsorption amount. The clinical benefit or harm of the BA adsorption needs to be evaluated in the future.
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Affiliation(s)
- Antonia Greimel
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | | | - Caroline Gräfe
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Nils Maciuga
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Clara Isabell Brozat
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Felix L Happich
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Sandra Frank
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany.
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Leber B, Liebchen U, Rohrhofer L, Weber J, Klaus T, Scheier J, Sucher R, Stiegler P. Pharmacokinetics of immunosuppressive agents during hemoperfusion in a sheep model. Front Med (Lausanne) 2023; 10:1258661. [PMID: 37928476 PMCID: PMC10623319 DOI: 10.3389/fmed.2023.1258661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Hemoadsorption shows promising signals in organ preservation and post lung transplantation. However, its potential impact on the pharmacokinetics of immunosuppressant drugs (ID) is still unknown. Methods In this interventional study, CytoSorb® hemoperfusion was tested in healthy sheep (n = 5) against a sham extracorporeal circuit (n = 3). Seven different ID (tacrolimus (TAC), cyclosporin A (CYA), mycophenolate mofetil (MMF), everolimus (EVER), basiliximab (BAS), methylprednisolone (MP) and prednisolone (PRED)) were administered in clinically relevant doses and combinations. Their levels were measured repeatedly in blood samples from the extracorporeal circulation over 6 h following administration. Population pharmacokinetic modeling analysis (NONMEM® 7.5) was performed. Results Negligible clearance was observed for PRED and BAS. For all other substances, a saturable adsorption sub-model with linear decrease of the adsorption effect over the adsorbed amount best described the measured concentrations. The maximum absolute adsorbed amounts (95% CI) for TAC, CYA, MMF, EVER, and MP were 0.040 (0.028-0.053), 1.15 (0.39-1.91), 4.17 (2.00-6.35), 0.0163 (0.007-0.026), and 53.4 mg (20.9-85.9), respectively, indicating an adsorption of less than 5% of the daily administered dosages for all investigated substances. Discussion In this large animal model, CytoSorb® hemoperfusion appears to have a limited effect on the clearance of tested ID.
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Affiliation(s)
- Bettina Leber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Munich, Germany
| | - Lisa Rohrhofer
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Jennifer Weber
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | | | | | - Robert Sucher
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Philipp Stiegler
- General, Visceral and Transplant Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
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Gräfe C, Paal M, Winkels M, Irlbeck M, Liebchen U, Scharf C. Correlation between Bilirubin Elimination with the Cytokine Adsorber CytoSorb® and Mortality in Critically Ill Patients with Hyperbilirubinemia. Blood Purif 2023; 52:849-856. [PMID: 37820591 DOI: 10.1159/000532059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/01/2023] [Accepted: 07/12/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Hyperbilirubinemia is often the first evidence for any kind of liver disorder and over one-third of all patients in intensive care units (ICU) show elevated bilirubin concentrations. In critically ill patients, high concentrations of serum bilirubin are correlated with a poor outcome. Therapies to lower bilirubin concentrations are often just symptomatically and their effect on the patients' outcome is hardly evaluated. Therefore, this study investigates whether the extracorporeal elimination of bilirubin with the cytokine adsorber CytoSorb® (CS) reduces mortality in patients with hyperbilirubinemia. METHODS Patients with bilirubin concentrations >10 mg/dL at the ICU were screened for evaluation from 2018 to 2020. Patients with kidney replacement therapy and older than 18 years were included. Patients with continuously decreasing bilirubin concentrations after liver transplantation or other liver support systems (i.e., Molecular Adsorbents Recirculating System [MARS®], Advanced Organ Support [ADVOS]) were excluded. CS therapy was used in clinical routine and was indicated by the treating physicians. Statistical analysis was performed with IBM SPSS statistics utilizing a multivariate model. Primary outcome measure was the effect of CS on the 30-day mortality. RESULTS Data from 82 patients (mean Simplified Acute Physiology Score [SAPS] II: 74 points, mean bilirubin: 18 mg/dL, mean lactate: 3.7 mmol/L) were analyzed. There were no significant differences in patients with and without CS treatment. The multivariate model showed no significant effect of CS therapy (p = 0.402) on the 30-day mortality. In addition, a significant effect of bilirubin concentration (p = 0.274) or Model for End-Stage Liver Disease score (p = 0.928) on the 30-day mortality could not be shown. In contrast, lactate concentration (p = 0.001, b = 0.044) and SAPS II (p = 0.025, b = 0.008) had significant impact on 30-day mortality. CONCLUSION The use of CS in patients with hyperbilirubinemia did not result in a significant reduction in 30-day mortality. Randomized and controlled studies with mortality as primary outcome measure are needed in the future to justify their use.
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Affiliation(s)
- Caroline Gräfe
- Department of Anesthesiology, LMU Hospital, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Martin Winkels
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | | | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Munich, Germany
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Gräfe C, Liebchen U, Greimel A, Maciuga N, Bruegel M, Irlbeck M, Weidhase L, Zoller M, Paal M, Scharf C. The effect of cytosorb® application on kidney recovery in critically ill patients with severe rhabdomyolysis: a propensity score matching analysis. Ren Fail 2023; 45:2259231. [PMID: 37728069 PMCID: PMC10512801 DOI: 10.1080/0886022x.2023.2259231] [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: 04/24/2023] [Accepted: 09/11/2023] [Indexed: 09/21/2023] Open
Abstract
Severe rhabdomyolysis frequently results in acute kidney injury (AKI) due to myoglobin accumulation with the need of kidney replacement therapy (KRT). The present study investigated whether the application of Cytosorb® (CS) led to an increased rate of kidney recovery in patients with KRT due to severe rhabdomyolysis. Adult patients with a myoglobin-concentration >10,000 ng/ml and KRT were included from 2014 to 2021. Exclusion criteria were chronic kidney disease and CS-treatment before study inclusion. Groups 1 and 2 were defined as KRT with and without CS, respectively. The primary outcome parameter was independence from KRT after 30 days. Propensity score (PS) matching was performed (predictors: myoglobin, SAPS-II, and age), and the chi2-test was used. 35 pairings could be matched (mean age: 57 vs. 56 years; mean myoglobin: 27,218 vs. 26,872 ng/ml; mean SAPS-II: 77 vs. 76). The probability of kidney recovery was significantly (p = .04) higher in group 1 (31.4 vs. 11.4%, mean difference: 20.0%, odds ratio (OR): 3.6). Considering patients who survived 30 days, kidney recovery was also significantly (p = .03) higher in patients treated with CS (61.1 vs. 23.5%, mean difference: 37.6%, OR: 5.1). In conclusion, the use of CS might positively affect renal recovery in patients with severe rhabdomyolysis. A prospective randomized controlled trial is needed to confirm this hypothesis.
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Affiliation(s)
- Caroline Gräfe
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | | | - Nils Maciuga
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | - Mathias Bruegel
- Institute of Laboratory Medicine, LMU hospital, Munich, Germany
| | | | - Lorenz Weidhase
- Medical Intensive Care Unit, University Hospital Leipzig, Leipzig, Germany
| | - Michael Zoller
- Department of Anesthesiology, LMU hospital, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU hospital, Munich, Germany
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Greppmair S, Brinkmann A, Roehr A, Frey O, Hagel S, Dorn C, Marsot A, El-Haffaf I, Zoller M, Saller T, Zander J, Schatz LM, Scharf C, Briegel J, Minichmayr IK, Wicha SG, Liebchen U. Towards model-informed precision dosing of piperacillin: multicenter systematic external evaluation of pharmacokinetic models in critically ill adults with a focus on Bayesian forecasting. Intensive Care Med 2023; 49:966-976. [PMID: 37439872 PMCID: PMC10425489 DOI: 10.1007/s00134-023-07154-0] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE Inadequate piperacillin (PIP) exposure in intensive care unit (ICU) patients threatens therapeutic success. Model-informed precision dosing (MIPD) might be promising to individualize dosing; however, the transferability of published models to external populations is uncertain. This study aimed to externally evaluate the available PIP population pharmacokinetic (PopPK) models. METHODS A multicenter dataset of 561 ICU patients (11 centers/3654 concentrations) was used for the evaluation of 24 identified models. Model performance was investigated for a priori (A) predictions, i.e., considering dosing records and patient characteristics only, and for Bayesian forecasting, i.e., additionally including the first (B1) or first and second (B2) therapeutic drug monitoring (TDM) samples per patient. Median relative prediction error (MPE) [%] and median absolute relative prediction error (MAPE) [%] were calculated to quantify accuracy and precision. RESULTS The evaluation revealed a large inter-model variability (A: MPE - 135.6-78.3% and MAPE 35.7-135.6%). Integration of TDM data improved all model predictions (B1/B2 relative improvement vs. A: |MPE|median_all_models 45.1/67.5%; MAPEmedian_all_models 29/39%). The model by Kim et al. was identified to be most appropriate for the total dataset (A/B1/B2: MPE - 9.8/- 5.9/- 0.9%; MAPE 37/27.3/23.7%), Udy et al. performed best in patients receiving intermittent infusion, and Klastrup et al. best predicted patients receiving continuous infusion. Additional evaluations stratified by sex and renal replacement therapy revealed further promising models. CONCLUSION The predictive performance of published PIP models in ICU patients varied considerably, highlighting the relevance of appropriate model selection for MIPD. Our differentiated external evaluation identified specific models suitable for clinical use, especially in combination with TDM.
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Affiliation(s)
- Sebastian Greppmair
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Anka Roehr
- Department of Pharmacy, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, 89522, Heidenheim, Germany
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, University Hospital, Friedrich-Schiller-University Jena, 07747, Jena, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, 93053, Regensburg, Germany
| | - Amélie Marsot
- Faculty of Pharmacy, University of Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada
| | - Ibrahim El-Haffaf
- Faculty of Pharmacy, University of Montréal, Pavillon Jean-Coutu, 2940 Chemin de Polytechnique, Montréal, QC, H3T 1J4, Canada
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Saller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Johannes Zander
- Laboratory Dr. Brunner, Laboratory Medical Care Center Konstanz GmbH, 78464, Constance, Germany
| | - Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, 48149, Muenster, Germany
| | - Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Josef Briegel
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacology, Medical University Vienna, 1090, Vienna, Austria
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146, Hamburg, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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Bilal M, Zoller M, Fuhr U, Jaehde U, Ullah S, Liebchen U, Büsker S, Zander J, Babouee Flury B, Taubert M. Cefepime Population Pharmacokinetics, Antibacterial Target Attainment, and Estimated Probability of Neurotoxicity in Critically Ill Patients. Antimicrob Agents Chemother 2023; 67:e0030923. [PMID: 37366614 PMCID: PMC10353438 DOI: 10.1128/aac.00309-23] [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: 03/08/2023] [Accepted: 06/01/2023] [Indexed: 06/28/2023] Open
Abstract
Cefepime has been reported to cause concentration-related neurotoxicity, especially in critically ill patients with renal failure. This evaluation aimed to identify a dosing regimen providing a sufficient probability of target attainment (PTA) and the lowest justifiable risk of neurotoxicity in critically ill patients. A population pharmacokinetic model was developed based on plasma concentrations over four consecutive days obtained from 14 intensive care unit (ICU) patients. The patients received a median dose of 2,000 mg cefepime by 30-min intravenous infusions with dosing intervals of every 8 h (q8h) to q24h. A time that the free drug concentration exceeds the MIC over the dosing interval (fT>MIC) of 65% and an fT>2×MIC of 100% were defined as treatment targets. Monte Carlo simulations were carried out to identify a dosing regimen for a PTA of 90% and a probability of neurotoxicity not exceeding 20%. A two-compartment model with linear elimination best described the data. Estimated creatinine clearance was significantly related to the clearance of cefepime in nondialysis patients. Interoccasion variability on clearance improved the model, reflecting dynamic clearance changes. The evaluations suggested combining thrice-daily administration as an appropriate choice. In patients with normal renal function (creatinine clearance, 120 mL/min), for the pharmacodynamics target of 100% fT>2×MIC and a PTA of 90%, a dose of 1,333 mg q8h was found to be related to a probability of neurotoxicity of ≤20% and to cover MICs up to 2 mg/L. Continuous infusion appears to be superior to other dosing regimens by providing higher efficacy and a low risk of neurotoxicity. The model makes it possible to improve the predicted balance between cefepime efficacy and neurotoxicity in critically ill patients. (This study has been registered at ClinicalTrials.gov under registration no. NCT01793012).
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Affiliation(s)
- Muhammad Bilal
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, Cologne, Germany
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Michael Zoller
- Department of Anaesthesiology, Hospital of the Ludwig Maximilians University of Munich, Munich, Germany
| | - Uwe Fuhr
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, Cologne, Germany
| | - Ulrich Jaehde
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Bonn, Bonn, Germany
| | - Sami Ullah
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, Cologne, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, Hospital of the Ludwig Maximilians University of Munich, Munich, Germany
| | - Sören Büsker
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, Cologne, Germany
| | | | - Baharak Babouee Flury
- Division of Infectious Diseases and Hospital Epidemiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Max Taubert
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Center for Pharmacology, Department I of Pharmacology, Cologne, Germany
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Chiriac U, Richter D, Frey OR, Röhr AC, Helbig S, Hagel S, Liebchen U, Weigand MA, Brinkmann A. Software- and TDM-Guided Dosing of Meropenem Promises High Rates of Target Attainment in Critically Ill Patients. Antibiotics (Basel) 2023; 12:1112. [PMID: 37508207 PMCID: PMC10376356 DOI: 10.3390/antibiotics12071112] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/13/2023] [Accepted: 06/19/2023] [Indexed: 07/30/2023] Open
Abstract
Various studies have reported insufficient beta-lactam concentrations in critically ill patients. The optimal dosing strategy for beta-lactams in critically ill patients, particularly in septic patients, is an ongoing matter of discussion. This retrospective study aimed to evaluate the success of software-guided empiric meropenem dosing (CADDy, Calculator to Approximate Drug-Dosing in Dialysis) with subsequent routine meropenem measurements and expert clinical pharmacological interpretations. Adequate therapeutic drug exposure was defined as concentrations of 8-16 mg/L, whereas concentrations of 16-24 mg/L were defined as moderately high and concentrations >24 mg/L as potentially harmful. A total of 91 patients received meropenem as a continuous infusion (229 serum concentrations), of whom 60% achieved 8-16 mg/L, 23% achieved 16-24 mg/L, and 10% achieved unnecessarily high and potentially harmful meropenem concentrations >24 mg/L in the first 48 h using the dosing software. No patient showed concentrations <2 mg/L using the dosing software in the first 48 h. With a subsequent TDM-guided dose adjustment, therapeutic drug exposure was significantly (p ≤ 0.05) enhanced to 70%. No patient had meropenem concentrations >24 mg/L with TDM-guided dose adjustments. The combined use of dosing software and consecutive TDM promised a high rate of adequate therapeutic drug exposures of meropenem in patients with sepsis and septic shock.
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Affiliation(s)
- Ute Chiriac
- Department of Pharmacy, Heidelberg University Hospital, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany
| | - Daniel Richter
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Otto R Frey
- Department of Clinical Pharmacy, Heidenheim Hospital, Schlosshaustraße 100, 89522 Heidenheim, Germany
| | - Anka C Röhr
- Department of Clinical Pharmacy, Heidenheim Hospital, Schlosshaustraße 100, 89522 Heidenheim, Germany
| | - Sophia Helbig
- Department of Clinical Pharmacy, Heidenheim Hospital, Schlosshaustraße 100, 89522 Heidenheim, Germany
| | - Stefan Hagel
- Institute for Infectious Diseases and Infection Control, Jena University Hospital-Friedrich Schiller University Jena, 07740 Jena, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Alexander Brinkmann
- Department of Anesthesiology, Heidenheim Hospital, Schlosshaustraße 100, 89522 Heidenheim, Germany
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11
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Chen Z, Taubert M, Chen C, Dokos C, Fuhr U, Weig T, Zoller M, Heck S, Dimitriadis K, Terpolilli N, Kinast C, Scharf C, Lier C, Dorn C, Liebchen U. Plasma and Cerebrospinal Fluid Population Pharmacokinetics of Vancomycin in Patients with External Ventricular Drain. Antimicrob Agents Chemother 2023; 67:e0024123. [PMID: 37162349 PMCID: PMC10269048 DOI: 10.1128/aac.00241-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/15/2023] [Indexed: 05/11/2023] Open
Abstract
Vancomycin is a commonly used antibacterial agent in patients with primary central nervous system (CNS) infection. This study aims to examine predictors of vancomycin penetration into cerebrospinal fluid (CSF) in patients with external ventricular drainage and the feasibility of CSF sampling from the distal drainage port for therapeutic drug monitoring. Fourteen adult patients (9 with primary CNS infection) were treated with vancomycin intravenously. The vancomycin concentrations in blood and CSF (from proximal [CSF_P] and distal [CSF_D] drainage ports) were evaluated by population pharmacokinetics. Model-based simulations were conducted to compare various infusion modes. A three-compartment model with first-order elimination best described the vancomycin data. Estimated parameters included clearance (CL, 4.53 L/h), central compartment volume (Vc, 24.0 L), apparent CSF compartment volume (VCSF, 0.445 L), and clearance between central and CSF compartments (QCSF, 0.00322 L/h and 0.00135 L/h for patients with and without primary CNS infection, respectively). Creatinine clearance was a significant covariate on vancomycin CL. CSF protein was the primary covariate to explain the variability of QCSF. There was no detectable difference between the data for sampling from the proximal and the distal port. Intermittent infusion and continuous infusion with a loading dose reached the CSF target concentration faster than continuous infusion only. All infusion schedules reached similar CSF trough concentrations. Beyond adjusting doses according to renal function, starting treatment with a loading dose in patients with primary CSF infection is recommended. Occasionally, very high and possibly toxic doses would be required to achieve adequate CSF concentrations, which calls for more investigation of direct intraventricular administration of vancomycin. (This study has been registered at ClinicalTrials.gov under registration no. NCT04426383).
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Affiliation(s)
- Zhendong Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Max Taubert
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Chunli Chen
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Heilongjiang Key Laboratory for Animal Disease Control and Pharmaceutical Development, College of Veterinary Medicine, Northeast Agricultural University, Harbin, People’s Republic of China
| | - Charalambos Dokos
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Uwe Fuhr
- Department I of Pharmacology, Center for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Weig
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, University Hospital, Ludwig Maximilian University, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig Maximilians University, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Christina Kinast
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
| | - Constantin Lier
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, Faculty of Chemistry and Pharmacy, University of Regensburg, Regensburg, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, Ludwig Maximilians University of Munich, Munich, Germany
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12
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Schatz LM, Brinkmann A, Röhr A, Frey O, Greppmair S, Weinelt F, Zoller M, Scharf C, Hempel G, Liebchen U. Systematic Evaluation of Pharmacokinetic Models for Model-Informed Precision Dosing of Meropenem in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Antimicrob Agents Chemother 2023; 67:e0010423. [PMID: 37125925 DOI: 10.1128/aac.00104-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
The altered pharmacokinetics of renally cleared drugs such as meropenem in critically ill patients receiving continuous renal replacement therapy (CRRT) might impact target attainment. Model-informed precision dosing (MIPD) is applied to individualize meropenem dosing. However, most population pharmacokinetic (PopPK) models developed to date have not yet been evaluated for MIPD. Eight PopPK models based on adult CRRT patients were identified in a systematic literature research and encoded in NONMEM 7.4. A data set of 73 CRRT patients from two different study centers was used to evaluate the predictive performance of the models using simulation and prediction-based diagnostics for i) a priori dosing based on patient characteristics only and ii) Bayesian dosing by including the first measured trough concentration. Median prediction error (MPE) for accuracy within |20%| (95% confidence intervals including zero) and median absolute prediction error (MAPE) for precision ≤ 30% were considered clinically acceptable. For a priori dosing, most models (n = 5) showed accuracy and precision MPE within |20%| and MAPE <35%. The integration of the first measured meropenem concentration improved the predictive performance of all models (median MAPE decreased from 35.4 to 25.0%; median MPE decreased from 21.8 to 4.6%). The best predictive performance for intermittent infusion was observed for the O'Jeanson model, including residual diuresis as covariate (a priori and Bayesian dosing MPE within |2%|, MAPE <30%). Our study revealed the O'Jeanson model as the best-predicting model for intermittent infusion. However, most of the selected PopPK models are suitable for MIPD in CRRT patients when one therapeutic drug monitoring sample is available.
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Affiliation(s)
- Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Anka Röhr
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Sebastian Greppmair
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Ferdinand Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
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13
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Liebchen U, Briegel J, Brinkmann A, Frey O, Wicha SG. Individualised dosing of antibiotics in ICU patients: timing, target and model selection matter. Intensive Care Med 2023; 49:475-476. [PMID: 36719458 PMCID: PMC10119245 DOI: 10.1007/s00134-023-06990-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany.
| | - Josef Briegel
- Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Alexander Brinkmann
- Department of Anaesthesiology and Intensive Care Medicine, General Hospital of Heidenheim, Heidenheim, Germany
| | - Otto Frey
- Department of Pharmacy, General Hospital of Heidenheim, Heidenheim, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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14
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Liebchen U, Briegel J, Scharf C. [What is new … in selective decontamination?]. Anaesthesiologie 2023; 72:273-274. [PMID: 36797534 DOI: 10.1007/s00101-023-01262-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Uwe Liebchen
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland.
| | - Josef Briegel
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
| | - Christina Scharf
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
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15
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Zoller M, Liebchen U, Scharf C. Authors' response: "Serum linezolid concentrations are reduced in critically ill patients with pulmonary infections: A prospective observational study". J Crit Care 2022; 72:154168. [PMID: 36241467 DOI: 10.1016/j.jcrc.2022.154168] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/26/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Michael Zoller
- Department of Anesthesiology, LMU Hospital, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Munich, Germany
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16
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Kinast CB, Paal M, Liebchen U. Comparison of Cerebrospinal Fluid Collection Through the Proximal and Distal Port Below the Overflow System from an External Ventricular Drain. Neurocrit Care 2022; 37:775-778. [PMID: 36229574 DOI: 10.1007/s12028-022-01615-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/20/2022] [Indexed: 10/17/2022]
Affiliation(s)
- Christina Barbara Kinast
- Department of Anesthesiology, University Hospital, Ludwig Maximilian University Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, Ludwig Maximilian University Munich, Marchioninistrasse 15, 81377, Munich, Germany.
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17
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Zoller M, Paal M, Greimel A, Kallee S, Vogeser M, Irlbeck M, Schroeder I, Liebchen U, Scharf C. Serum linezolid concentrations are reduced in critically ill patients with pulmonary infections: A prospective observational study. J Crit Care 2022; 71:154100. [PMID: 35780622 DOI: 10.1016/j.jcrc.2022.154100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 12/15/2022]
Abstract
RATIONALE The concentration-time profile of linezolid varies considerably in critically ill patients. Question of interest is, if the site of infection influences linezolid serum concentrations. METHODS 68 critically ill patients, treated with linezolid, were included. The concentration-time-profile for linezolid was determined using maximum a-posteriori predictions. A trough concentration (Cmin) between 2 and 10 mg/L was defined as the target. A generalized linear model (GLM) was established to evaluate potential covariates. RESULTS The indications for linezolid therapy were in descending order: peritonitis (38.2%), pneumonia (25.0%), infectious acute respiratory distress syndrome (ARDS) (19.1%), and other non-pulmonary infection (17.7%). 27.2 and 7.9% of Cmin were subtherapeutic and toxic, respectively. In the GLM, ARDS (mean: -2.1 mg/L, CI: -3.0 to -1.2 mg/L) and pneumonia (mean: -2.2 mg/L, CI: -2.8 to -1.6 mg/L) were significant (p < 0.001) determinants of Cmin. Patients with ARDS (mean: 2.3 mg/L, 51.2% subtherapeutic, 0.0% toxic) and pneumonia (mean: 3.5 mg/L, 41.5% subtherapeutic, 7.7% toxic) had significantly (p < 0.001) lower Cmin than those with peritonitis (mean: 5.5 mg/L, 14.4% subtherapeutic, 9.3% toxic) and other non-pulmonary infection (mean: 5.2 mg/L, 3.3% subtherapeutic, 16.5% toxic). CONCLUSION Linezolid serum concentrations are reduced in patients with pulmonary infections. Future studies should investigate if other linezolid thresholds are needed in those patients due to linezolid pooling in patients´ lung.
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Affiliation(s)
- Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University hospital, LMU Munich, Germany
| | - Antonia Greimel
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Simon Kallee
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University hospital, LMU Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Germany.
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18
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Kallee S, Scharf C, Schatz LM, Paal M, Vogeser M, Irlbeck M, Zander J, Zoller M, Liebchen U. Systematic Evaluation of Voriconazole Pharmacokinetic Models without Pharmacogenetic Information for Bayesian Forecasting in Critically Ill Patients. Pharmaceutics 2022; 14:pharmaceutics14091920. [PMID: 36145667 PMCID: PMC9505877 DOI: 10.3390/pharmaceutics14091920] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Voriconazole (VRC) is used as first line antifungal agent against invasive aspergillosis. Model-based approaches might optimize VRC therapy. This study aimed to investigate the predictive performance of pharmacokinetic models of VRC without pharmacogenetic information for their suitability for model-informed precision dosing. Seven PopPK models were selected from a systematic literature review. A total of 66 measured VRC plasma concentrations from 33 critically ill patients was employed for analysis. The second measurement per patient was used to calculate relative Bias (rBias), mean error (ME), relative root mean squared error (rRMSE) and mean absolute error (MAE) (i) only based on patient characteristics and dosing history (a priori) and (ii) integrating the first measured concentration to predict the second concentration (Bayesian forecasting). The a priori rBias/ME and rRMSE/MAE varied substantially between the models, ranging from −15.4 to 124.6%/−0.70 to 8.01 mg/L and from 89.3 to 139.1%/1.45 to 8.11 mg/L, respectively. The integration of the first TDM sample improved the predictive performance of all models, with the model by Chen (85.0%) showing the best predictive performance (rRMSE: 85.0%; rBias: 4.0%). Our study revealed a certain degree of imprecision for all investigated models, so their sole use is not recommendable. Models with a higher performance would be necessary for clinical use.
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Affiliation(s)
- Simon Kallee
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, 48149 Muenster, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Johannes Zander
- Laboratory Dr. Brunner, Luisenstr. 7e, 78464 Konstanz, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
- Correspondence: ; Tel.: +49-89-4400-1681160
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19
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Kipka H, Tomasi R, Hübner M, Liebchen U, Hagl C, Wanner KT, Mannell H, Höfner G. Simultaneous LC-ESI-MS/MS Quantification of Levosimendan and Its Metabolites for Therapeutic Drug Monitoring of Cardiac Surgery Patients. Pharmaceutics 2022; 14:pharmaceutics14071454. [PMID: 35890349 PMCID: PMC9319272 DOI: 10.3390/pharmaceutics14071454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 06/08/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 02/04/2023] Open
Abstract
Levosimendan is used in severe chronic cardiac insufficiency, also within the peri-operative setting. Real-life pharmacokinetic data in surgical patients is lacking, making therapeutic drug monitoring (TDM) of levosimendan, its pharmacologically active metabolite OR-1896, and its intermediate OR-1855 important. A simultaneous highly sensitive quantification of levosimendan and its metabolites in small-volume samples has not yet been described. Here, levosimendan (LLOQ 0.450 nM), OR-1896, and OR-1855 (LLOQ both 1.0 nM) were successfully quantified by LC-ESI-MS/MS after liquid-liquid extraction in 300 µL of blood. A short C8 column under reversed-phase conditions enabled simultaneous and fast quantification of levosimendan in the negative and the metabolites in the positive ionization mode in a single run within 2 min. Interestingly and unexpectedly, constitutional isomers of levosimendan metabolites with identical mass transitions and similar retention times were observed in surgical patients’ samples, which we identified as the metamizole metabolites 4-aminoantipyrine and 4-acetamidoantipyrine. A longer C8 column and a modified mobile phase enabled selective quantification of all analytes in a single run within 7 min. We developed, validated, and applied highly sensitive LC-ESI-MS/MS methods for simultaneous quantification of levosimendan and its metabolites, enabling efficient TDM of cardiac surgery patients even with additional metamizole administration.
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Affiliation(s)
- Hannah Kipka
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany;
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
- Correspondence:
| | - Roland Tomasi
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
| | - Max Hübner
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
- Walter Brendel Center of Experimental Medicine, LMU Munich, 81377 Munich, Germany
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (R.T.); (M.H.); (U.L.)
| | - Christian Hagl
- Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany;
- DZHK (German Centre of Cardiovascular Research), Partner Site Munich Heart Alliance, 81377 Munich, Germany
| | - Klaus T. Wanner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität, 81377 Munich, Germany; (K.T.W.); (G.H.)
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, 81377 Munich, Germany;
- Institute of Cardiovascular Physiology and Pathophysiology, Biomedical Center, LMU Munich, 82152 Planegg, Germany
| | - Georg Höfner
- Department of Pharmacy, Center for Drug Research, Ludwig-Maximilians-Universität, 81377 Munich, Germany; (K.T.W.); (G.H.)
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20
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Schatz LM, Zoller M, Scharf C, Liebchen U. [Therapeutic drug monitoring and pharmacokinetic models as a strategy for rational antibiotic therapy in intensive care patients]. Anaesthesiologie 2022; 71:495-501. [PMID: 35925054 DOI: 10.1007/s00101-022-01150-7] [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] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Antibiotic dosing in intensive care patients is complex due to pharmacokinetic (PK) alterations. The aim of this article is to illustrate the role of therapeutic drug monitoring (TDM) and PK models to individualize antibiotic dosing. MATERIAL AND METHODS Guidelines and recommendations are discussed in the context of clinical practice and the prerequisites for routine TDM of different antibiotics are presented. In addition, the benefits and limitations of TDM are discussed. The advantages and disadvantages of TDM and PK models are described and the resulting future options are presented. RESULTS In the clinical routine, the peak or trough concentrations of antibiotics in blood are measured depending on the antibiotic class. Prerequisites for a purposeful TDM are a coordinated blood sampling and a prompt reporting of findings. As target ranges are not uniformly defined following rules, dosage adjustments are difficult. The PK models offer a valid possibility to individualize the antibiotic therapy of intensive care patients. Areas of application are the calculation of the loading dose and the combination with TDM for treatment control. For whom and how often TDM is necessary and how it can best be combined with PK models or even replace them should be investigated in the future, in addition to evaluation of the optimal target area. CONCLUSION The routine use of TDM for antibiotics in intensive care patients is only effective under the abovementioned conditions. By combination with PK models the treatment could be optimized in the future.
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Affiliation(s)
- Lea Marie Schatz
- Institut für Klinische Pharmazie, Westfälische Wilhelms-Universität Münster, Münster, Deutschland
| | - Michael Zoller
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
| | - Christina Scharf
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
| | - Uwe Liebchen
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland.
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21
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Liebchen U, Scharf C. Authors response: "Trough concentrations of meropenem and piperacillin during slow extended dialysis in critically ill patients with intermittent and continuous infusion: A prospective observational study". J Crit Care 2022; 70:154060. [PMID: 35623109 DOI: 10.1016/j.jcrc.2022.154060] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377 Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377 Munich, Germany.
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Scharf C, Weinelt F, Schroeder I, Paal M, Weigand M, Zoller M, Irlbeck M, Kloft C, Briegel J, Liebchen U. Does the cytokine adsorber CytoSorb ® reduce vancomycin exposure in critically ill patients with sepsis or septic shock? a prospective observational study. Ann Intensive Care 2022; 12:44. [PMID: 35599248 PMCID: PMC9124739 DOI: 10.1186/s13613-022-01017-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 05/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hemadsorption of cytokines is used in critically ill patients with sepsis or septic shock. Concerns have been raised that the cytokine adsorber CytoSorb® unintentionally adsorbs vancomycin. This study aimed to quantify vancomycin elimination by CytoSorb®. METHODS Critically ill patients with sepsis or septic shock receiving continuous renal replacement therapy and CytoSorb® treatment during a prospective observational study were included in the analysis. Vancomycin pharmacokinetics was characterized using population pharmacokinetic modeling. Adsorption of vancomycin by the CytoSorb® was investigated as linear or saturable process. The final model was used to derive dosing recommendations based on stochastic simulations. RESULTS 20 CytoSorb® treatments in 7 patients (160 serum samples/24 during CytoSorb®-treatment, all continuous infusion) were included in the study. A classical one-compartment model, including effluent flow rate of the continuous hemodialysis as linear covariate on clearance, best described the measured concentrations (without CytoSorb®). Significant adsorption with a linear decrease during CytoSorb® treatment was identified (p < 0.0001) and revealed a maximum increase in vancomycin clearance of 291% (initially after CytoSorb® installation) and a maximum adsorption capacity of 572 mg. For a representative patient of our cohort a reduction of the area under the curve (AUC) by 93 mg/L*24 h during CytoSorb® treatment was observed. The additional administration of 500 mg vancomycin over 2 h during CytoSorb® attenuated the effect and revealed a negligible reduction of the AUC by 4 mg/L*24 h. CONCLUSION We recommend the infusion of 500 mg vancomycin over 2 h during CytoSorb® treatment to avoid subtherapeutic concentrations. Trial registration NCT03985605. Registered 14 June 2019, https://clinicaltrials.gov/ct2/show/NCT03985605.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ferdinand Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Freie Universität Berlin/Universität Potsdam, Berlin, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Weigand
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Josef Briegel
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany. .,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Liebchen U, Paal M, Bucher V, Vogeser M, Irlbeck M, Schroeder I, Zoller M, Scharf C. Trough concentrations of meropenem and piperacillin during slow extended dialysis in critically ill patients with intermittent and continuous infusion: A prospective observational study. J Crit Care 2021; 67:26-32. [PMID: 34628123 DOI: 10.1016/j.jcrc.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/28/2022]
Abstract
Beta-lactam dosing is challenging in critically ill patients with slow extended daily dialysis (SLEDD). This prospective observational study aimed to investigate meropenem and piperacillin concentrations and half-lives during SLEDD and in SLEDD-free intervals. Critically ill patients with SLEDD-therapy and meropenem or piperacillin therapy were included. Breakpoints of target attainment were defined as 2 and 20.8 mg/L for meropenem and piperacillin, respectively. Daily TDM was performed and therapies were adapted based on the measured concentrations. Elimination rate constants were determined by using nonlinear regression analysis. Seventeen patients were included (48 SLEDD intervals; median SLEDD-duration: 7.25 h). The median antibiotic trough concentrations and half-lives were significantly (p < 0.001) lower during and after the SLEDD-therapy compared to SLEDD-free intervals (median meropenem: 22.3 (IQR: 12.8, 25.6) vs. 28.3 mg/L (IQR: 16.9, 37.4); median piperacillin: 55.8 (IQR: 45.1, 84.9) vs. 130 mg/L (IQR: 91.5, 154.5); relative change: -48.0% each, IQR meropenem: -33.3, -58.5%; IQR piperacillin: -36.3, -52.1%). However, none of the measured trough concentrations were subtherapeutic during SLEDD. SLEDD leads to a reduction in meropenem and piperacillin concentrations of approximately 50% independently of the initial concentration. If the concentration is twice as high as the breakpoint of target attainment before SLEDD-therapy, subtherapeutic levels can be avoided.
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Affiliation(s)
- Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Veronika Bucher
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Germany.
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Liebchen U, Scharf C, Zoller M, Weinelt F, Kloft C. No clinically relevant removal of meropenem by cytokine adsorber CytoSorb ® in critically ill patients with sepsis or septic shock. Intensive Care Med 2021; 47:1332-1333. [PMID: 34519848 PMCID: PMC8550492 DOI: 10.1007/s00134-021-06487-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ferdinand Weinelt
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.,Graduate Research Training Program PharMetrX, Freie Universität Berlin/Universität Potsdam, Berlin, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169, Berlin, Germany.
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Scharf C, Schroeder I, Paal M, Winkels M, Irlbeck M, Zoller M, Liebchen U. Can the cytokine adsorber CytoSorb ® help to mitigate cytokine storm and reduce mortality in critically ill patients? A propensity score matching analysis. Ann Intensive Care 2021; 11:115. [PMID: 34292421 PMCID: PMC8295971 DOI: 10.1186/s13613-021-00905-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/10/2021] [Indexed: 02/06/2023] Open
Abstract
Background A cytokine storm is life threatening for critically ill patients and is mainly caused by sepsis or severe trauma. In combination with supportive therapy, the cytokine adsorber Cytosorb® (CS) is increasingly used for the treatment of cytokine storm. However, it is questionable whether its use is actually beneficial in these patients. Methods Patients with an interleukin-6 (IL-6) > 10,000 pg/ml were retrospectively included between October 2014 and May 2020 and were divided into two groups (group 1: CS therapy; group 2: no CS therapy). Inclusion criteria were a regularly measured IL-6 and, for patients allocated to group 1, CS therapy for at least 90 min. A propensity score (PS) matching analysis with significant baseline differences as predictors (Simplified Acute Physiology Score (SAPS) II, extracorporeal membrane oxygenation, renal replacement therapy, IL-6, lactate and norepinephrine demand) was performed to compare both groups (adjustment tolerance: < 0.05; standardization tolerance: < 10%). U-test and Fisher’s-test were used for independent variables and the Wilcoxon test was used for dependent variables. Results In total, 143 patients were included in the initial evaluation (group 1: 38; group 2: 105). Nineteen comparable pairings could be formed (mean initial IL-6: 58,385 vs. 59,812 pg/ml; mean SAPS II: 77 vs. 75). There was a significant reduction in IL-6 in patients with (p < 0.001) and without CS treatment (p = 0.005). However, there was no significant difference (p = 0.708) in the median relative reduction in both groups (89% vs. 80%). Furthermore, there was no significant difference in the relative change in C-reactive protein, lactate, or norepinephrine demand in either group and the in-hospital mortality was similar between groups (73.7%). Conclusion Our study showed no difference in IL-6 reduction, hemodynamic stabilization, or mortality in patients with Cytosorb® treatment compared to a matched patient population.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, University Hospital LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital LMU Munich, Munich, Germany
| | - Martin Winkels
- Institute of Laboratory Medicine, University Hospital LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Kallee S, Scharf C, Schroeder I, Paal M, Vogeser M, Irlbeck M, Zander J, Zoller M, Jung J, Kneidinger N, Schneider C, Michel S, Liebchen U. Comparing posaconazole and itraconazole for antifungal prophylaxis in critically ill lung transplant recipients: Efficacy and plasma concentrations. Transpl Infect Dis 2021; 23:e13675. [PMID: 34166573 DOI: 10.1111/tid.13675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/19/2021] [Accepted: 05/30/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Posaconazole and itraconazole are commonly used for systemic antifungal prophylaxis after lung transplantation. The aim of this study on critically ill lung transplant recipients was to assess the rate of adequate plasma concentrations and the frequency of fungal-induced transitions from antifungal prophylaxis to therapy after the administration of either posaconazole or itraconazole for systemic prophylaxis. METHODS Critically ill lung transplant recipients with postoperative posaconazole or itraconazole prophylaxis and therapeutic drug monitoring from February 2016 to November 2019 were retrospectively included in the study. Positive fungal cultures or Aspergillus antigen tests resulting in a transition from antifungal prophylaxis to therapy were analyzed from the first day of prophylaxis until 7 days after the last sample for each patient. Adequate plasma concentrations were defined as ≥500 µg/L for itraconazole and ≥700 µg/L for posaconazole. RESULTS Two hundred seventy-five samples from 73 patients were included in the analysis. Overall, 60% of the posaconazole and 55% of the itraconazole concentrations were subtherapeutic. Administration of posaconazole suspension resulted significantly (P < .01) more often in subtherapeutic concentrations than tablets (68% vs 10%). Patients treated with posaconazole showed less positive fungal records resulting in a transition from prophylaxis to therapy than patients treated with itraconazole (10% vs 33%, P-value: .029). The detection of a fungal pathogen was not associated with the measured plasma concentrations or the achievement of the target concentrations. CONCLUSION Our findings suggest that posaconazole should be used instead of itraconazole for systemic prophylaxis in critically ill lung transplant recipients.
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Affiliation(s)
- Simon Kallee
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Jette Jung
- Max-von-Pettenkofer-Institute Munich, Ludwig Maximilian University, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, University Hospital, LMU Munich, Comprehensive Pneumology Center (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Christian Schneider
- Department of Thoracic Surgery, University Hospital, LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Sebastian Michel
- Department of Cardiac Surgery, University Hospital LMU Munich, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
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Scharf C, Liebchen U, Paal M, Becker-Pennrich A, Irlbeck M, Zoller M, Schroeder I. Successful elimination of bilirubin in critically ill patients with acute liver dysfunction using a cytokine adsorber and albumin dialysis: a pilot study. Sci Rep 2021; 11:10190. [PMID: 33986443 PMCID: PMC8119427 DOI: 10.1038/s41598-021-89712-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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] [Received: 02/22/2021] [Accepted: 04/29/2021] [Indexed: 12/15/2022] Open
Abstract
There are different methods of artificial liver support for patients with acute liver dysfunction (ALD). However, CytoSorb (CS) might be a new approved option for those patients. Question of interest is whether the elimination performance of CS was comparable to that of advanced organ support (ADVOS). Patients, treated with CS (integrated into high-flux dialysis) or ADVOS and a total bilirubin > 10 mg/dl were included. Laboratory parameters were evaluated before starting therapy (d0) and 12–24 h thereafter (d1). The Wilcoxon-test with associated samples was used for statistical analysis. Thirty-nine patients (33 CS, 6 ADVOS) were included. The median bilirubin at d0 was 16.9 and 17.7 mg/dl and at d1 was 13.2 and 15.9 mg/dl, in the CS and ADVOS group, respectively. There was a significant bilirubin reduction as well in the CS group (p < 0.001, median relative reduction: 22.5%) as in the ADVOS group (p = 0.028, median relative reduction: 22.8%). There was no significant difference in the relative bilirubin reduction between CS and ADVOS therapies. The use of CytoSorb and ADVOS in patients with ALD led to a significant and comparable decrease in total bilirubin. The easy use of CS might be an advantage compared to other procedures.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Andrea Becker-Pennrich
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
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Scharf C, Zoller M, Liebchen U. [What is new … in the treatment of invasive mycosis: COVID-19-associated pulmonary aspergillosis]. Anaesthesist 2021; 70:432-433. [PMID: 33635372 PMCID: PMC7908936 DOI: 10.1007/s00101-021-00931-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Christina Scharf
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland.
| | - Michael Zoller
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland
| | - Uwe Liebchen
- Klinik für Anästhesiologie, LMU Klinikum, Marchioninistraße 15, 81377, München, Deutschland
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Habler K, Brügel M, Teupser D, Liebchen U, Scharf C, Schönermarck U, Vogeser M, Paal M. Simultaneous quantification of seven repurposed COVID-19 drugs remdesivir (plus metabolite GS-441524), chloroquine, hydroxychloroquine, lopinavir, ritonavir, favipiravir and azithromycin by a two-dimensional isotope dilution LC-MS/MS method in human serum. J Pharm Biomed Anal 2021; 196:113935. [PMID: 33548872 PMCID: PMC7843035 DOI: 10.1016/j.jpba.2021.113935] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/30/2020] [Accepted: 01/24/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The present COVID-19 pandemic has prompted worldwide repurposing of drugs. The aim of the present work was to develop and validate a two-dimensional isotope-dilution liquid chromatrography tandem mass spectrometry (ID-LC-MS/MS) method for accurate quantification of remdesivir and its active metabolite GS-441524, chloroquine, hydroxychloroquine, lopinavir, ritonavir, favipiravir and azithromycin in serum; drugs that have gained attention for repurposing in the treatment of COVID-19. METHODS Following protein precipitation, samples were separated with a two-dimensional ultra-high performance liquid chromatography (2D-UHPLC) setup, consisting of an online solid phase extraction (SPE) coupled to an analytical column. For quantification, stable isotope-labelled analogues were used as internal standards for all analytes. The method was validated on the basis of the European Medicines Agency bioanalytical method validation protocol. RESULTS Detuning of lopinavir and ritonavir allowed simultaneous quantification of all analytes with different concentration ranges and sensitivity with a uniform injection volume of 5 μL. The method provided robust validation results with inaccuracy and imprecision values of ≤ 9.59 % and ≤ 11.1 % for all quality controls. CONCLUSION The presented method is suitable for accurate and simultaneous quantification of remdesivir, its metabolite GS-441525, chloroquine, hydroxychloroquine, lopinavir, ritonavir, favipiravir and azithromycin in human serum. The quantitative assay may be an efficient tool for the therapeutic drug monitoring of these potential drug candidates in COVID-19 patients in order to increase treatment efficacy and safety.
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Affiliation(s)
- Katharina Habler
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Mathias Brügel
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Daniel Teupser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, Germany
| | - Ulf Schönermarck
- Department of Medicine IV, University Hospital, LMU Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany.
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Scharf C, Liebchen U, Paal M, Irlbeck M, Zoller M, Schroeder I. Blood purification with a cytokine adsorber for the elimination of myoglobin in critically ill patients with severe rhabdomyolysis. Crit Care 2021; 25:41. [PMID: 33509234 PMCID: PMC7844984 DOI: 10.1186/s13054-021-03468-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Rhabdomyolysis is frequently occurring in critically ill patients, resulting in a high risk of acute kidney injury (AKI) and potentially permanent kidney damage due to increased myoglobin levels. The extracorporeal elimination of myoglobin might be an approach to prevent AKI, but its molecular weight of 17 kDa complicates an elimination with conventional dialysis membranes. Question of interest is, if myoglobin can be successfully eliminated with the cytokine adsorber Cytosorb® (CS) integrated in a high-flux dialysis system. METHODS Patients were included between 10/2014 and 05/2020 in the study population if they had an anuric renal failure with the need of renal replacement therapy, if CS therapy was longer than 90 min and if myoglobin level was > 5.000 ng/ml before treatment. The measurement times of the laboratory values were: d-1 = 24-36 h before CS, d0 = shortly before starting CS and d1 = 12-24 h after starting CS treatment. Statistical analysis were performed with Spearman's correlation coefficient, Wilcoxon test with associated samples and linear regression analysis. RESULTS Forty-three patients were included in the evaluation (median age: 56 years, 77% male patients, 32.6% ECMO therapy, median SAPS II: 80 points and in-hospital mortality: 67%). There was a significant equilateral correlation between creatine kinase (CK) and myoglobin at all measurement points. Furthermore, there was a significant reduction of myoglobin (p = 0.03, 95% confidence interval (CI): - 9030, - 908 ng/ml) during CS treatment, with a median relative reduction of 29%. A higher median reduction of 38% was seen in patients without ongoing rhabdomyolysis (CK decreased during CS treatment, n = 21). In contrast, myoglobin levels did not relevantly change in patients with increasing CK and therefore ongoing rhabdomyolysis (n = 22, median relative reduction 4%). Moreover, there was no significant difference in myoglobin elimination in patients with and without ECMO therapy. CONCLUSION Blood purification with Cytosorb® during high-flux dialysis led to a significant reduction of myoglobin in patients with severe rhabdomyolysis. The effect might be obscured by sustained rhabdomyolysis, which was seen in patients with rising CK during treatment. Prospective clinical trials would be useful in investigating its benefits in avoiding permanent kidney damage.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
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Scharf C, Liebchen U, Paal M, Taubert M, Vogeser M, Irlbeck M, Zoller M, Schroeder I. The higher the better? Defining the optimal beta-lactam target for critically ill patients to reach infection resolution and improve outcome. J Intensive Care 2020; 8:86. [PMID: 33292582 PMCID: PMC7686672 DOI: 10.1186/s40560-020-00504-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/08/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Beta-lactam antibiotics are often subject to therapeutic drug monitoring, but breakpoints of target attainment are mostly based on expert opinions. Studies that show a correlation between target attainment and infection resolution are missing. This analysis investigated whether there is a difference in infection resolution based on two breakpoints of target attainment. METHODS An outcome group out of 1392 critically ill patients treated with meropenem or piperacillin-tazobactam was formed due to different selection criteria. Afterwards, three groups were created: group 1=free drug concentration (f) was < 100% of the time (T) above the minimal inhibitory concentration (MIC) (< 100% fT > MIC), group 2=100% fT > MIC < 4xMIC, and group 3=100% fT > 4xMIC. Parameters for infection control, renal and liver function, and estimated and observed in-hospital mortality were compared between those groups. Statistical analysis was performed with one-way analysis of variance, Tukey post hoc test, U test, and bivariate logistic regression. RESULTS The outcome group consisted of 55 patients (groups 1-3, 17, 24, and 14 patients, respectively). Patients allocated to group 2 or 3 had a significantly faster reduction of the C-reactive protein in contrast to patients allocated to group 1 (p = 0.033 and p = 0.026). Patients allocated to group 3 had a worse renal function, a higher Acute Physiology and Chronic Health Evaluation (APACHE II) score, were older, and had a significantly higher in-hospital mortality compared to group 1 (p = 0.017) and group 2 (p = 0.001). The higher mortality was significantly influenced by worse liver function, higher APACHE II, and higher Sequential Organ Failure Assessment (SOFA) score and norepinephrine therapy. CONCLUSION Achieving the target 100% fT > MIC leads to faster infection resolution in the critically ill. However, there was no benefit for patients who reached the highest target of 100% fT > 4xMIC, although the mortality rate was higher possibly due to confounding effects. In conclusion, we recommend the target 100% fT > MIC < 4xMIC for critically ill patients. TRIAL REGISTRATION NCT03985605.
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Affiliation(s)
- Christina Scharf
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Max Taubert
- Department I of Pharmacology, Centre for Pharmacology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Michael Irlbeck
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anaesthesiology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377, Munich, Germany
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Scharf C, Paal M, Schroeder I, Vogeser M, Draenert R, Irlbeck M, Zoller M, Liebchen U. Therapeutic Drug Monitoring of Meropenem and Piperacillin in Critical Illness-Experience and Recommendations from One Year in Routine Clinical Practice. Antibiotics (Basel) 2020; 9:antibiotics9030131. [PMID: 32245195 PMCID: PMC7148485 DOI: 10.3390/antibiotics9030131] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/19/2022] Open
Abstract
Various studies have reported insufficient beta-lactam concentrations in critically ill patients. The extent to which therapeutic drug monitoring (TDM) in clinical practice can reduce insufficient antibiotic concentrations is an ongoing matter of investigation. We retrospectively evaluated routine meropenem and piperacillin measurements in critically ill patients who received antibiotics as short infusions in the first year after initiating a beta-lactam TDM program. Total trough concentrations above 8.0 mg/L for meropenem and above 22.5 mg/L for piperacillin were defined as the breakpoints for target attainment. We included 1832 meropenem samples and 636 piperacillin samples. We found that 39.3% of meropenem and 33.6% of piperacillin samples did not reach the target concentrations. We observed a clear correlation between renal function and antibiotic concentration (meropenem, r = 0.53; piperacillin, r = 0.63). Patients with renal replacement therapy or creatinine clearance (CrCl) of <70 mL/min had high rates of target attainment with the standard dosing regimens. There was a low number of patients with a CrCl >100 mL/min that achieved the target concentrations with the maximum recommended dosage. Patients with impaired renal function only required TDM if toxic side effects were noted. In contrast, patients with normal renal function required different dosage regimens and TDM-guided therapy to reach the breakpoints of target attainment.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
- Correspondence: ; Fax: +49-89-4400-78886
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Ines Schroeder
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany; (M.P.); (M.V.)
| | - Rika Draenert
- Section Clinical Infectious Diseases, University Hospital, LMU Munich, 81377 Munich, Germany;
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany; (I.S.); (M.I.); (M.Z.); (U.L.)
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Paal M, Heilmann M, Koch S, Bertsch T, Steinmann J, Höhl R, Liebchen U, Schuster C, Kleine FM, Vogeser M. Comparative LC-MS/MS and HPLC-UV Analyses of Meropenem and Piperacillin in Critically Ill Patients. Clin Lab 2020; 65. [PMID: 31532096 DOI: 10.7754/clin.lab.2019.190210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of beta-lactam antibiotics has become a valuable tool to guide dosing in critically ill patients. The main goal of the study was to compare two routinely used techniques for beta-lactam TDM in intensive care unit (ICU) patient samples, namely isotope dilution liquid chromatography tandem mass spectrometry (ID-LC-MS/MS) and high-performance liquid chromatography combined with ultra-violet detection (HPLC-UV). METHODS A set of 80 sera/plasma samples from ICU patients receiving therapeutic meropenem or piperacillin dosage was investigated. Sample duplicates and quality assessment samples were assayed in parallel with an in-house LC-MS/MS and a commercially available IVD HPLC-UV kit. A pharmacokinetic and pharmacodynamic (PK/PD) target with ≥ 22.5 mg/L for piperacillin and ≥ 8.0 mg/L for meropenem was used for medical assessment of trough sample (n = 40) antibiotic concentrations. RESULTS There was no difference between serum and Li-heparin plasmas. Concentration deviations were found for 4% of meropenem and 17% of piperacillin samples. Eliminating the influence of the systemic bias of approximately 10% for piperacillin, measurement discrepancies ≥ 25% between LC-MS/MS and HPLC-UV analyses were only observed for ≈ 4 - 6% of all samples. In the same way, identical PK/PD target attainment rates of 50 - 60% could be obtained. CONCLUSIONS After correction of the analytical bias for piperacillin measurements, both methods showed comparable results, also with respect to clinical decision limits. HPLC-UV analysis is an adequate TDM methodology for testing of beta-lactam antibiotics in centers where no special knowledge in LC-MS/MS based TDM is present. However, potential matrix effects, interferences, and calibration issues for both methods must be taken into account.
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Schuster C, Paal M, Lindner J, Zoller M, Liebchen U, Scharf C, Vogeser M. Isotope dilution LC-orbitrap-HRMS with automated sample preparation for the simultaneous quantification of 11 antimycotics in human serum. J Pharm Biomed Anal 2019; 166:398-405. [PMID: 30711809 DOI: 10.1016/j.jpba.2019.01.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/24/2019] [Indexed: 01/12/2023]
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Dorn C, Kratzer A, Liebchen U, Schleibinger M, Murschhauser A, Schlossmann J, Kees F, Simon P, Kees MG. Impact of Experimental Variables on the Protein Binding of Tigecycline in Human Plasma as Determined by Ultrafiltration. J Pharm Sci 2017; 107:739-744. [PMID: 28927988 DOI: 10.1016/j.xphs.2017.09.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 07/26/2017] [Revised: 09/11/2017] [Accepted: 09/11/2017] [Indexed: 11/17/2022]
Abstract
Tigecycline, a tetracycline derivative, shows atypical plasma protein binding behavior. The unbound fraction decreases with increasing concentration at therapeutic concentrations. Moreover, uncertainty exists about the magnitude of tigecyline's protein binding in man. Unbound fractions between 2.5% and 35% have been reported in plasma from healthy volunteers, and between 25% and 100% in patients, respectively. In the present study, the protein binding of tigecycline has been investigated by ultrafiltration using different experimental conditions. Whereas temperature had only a marginal influence, the unbound fraction at 0.3/3.0 mg/L was low at pH 8.2 (9.4%/1.9%) or in unbuffered pooled plasma (6.3%/1.2%), compared with plasma buffered with HEPES to pH 7.4 (65.9%/39.7%). In experiments with phosphate buffer and EDTA, the concentration dependency was markedly attenuated or abolished, which is compatible with a cooperative binding mechanism involving divalent cations such as calcium. The unbound fraction in clinical plasma samples from patients treated with tigecycline was determined to 66.3 ± 13.7% at concentrations <0.3 mg/L compared with 41.3 ± 16.0% at >1 to <5 mg/L. To summarize, tigecycline appears to be only moderately bound to plasma proteins as determined by ultrafiltration, when a physiological pH is maintained.
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Affiliation(s)
- Christoph Dorn
- Department of Clinical Pharmacy, University of Regensburg, Regensburg, Germany.
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Regensburg, Germany
| | - Uwe Liebchen
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | - Michael Schleibinger
- Department of Internal Medicine I, University Hospital Regensburg, Regensburg, Germany
| | | | - Jens Schlossmann
- Department of Pharmacology, University of Regensburg, Regensburg, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Regensburg, Germany
| | - Philipp Simon
- Department of Anesthesia and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Martin G Kees
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
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Schleibinger M, Steinbach CL, Töpper C, Kratzer A, Liebchen U, Kees F, Salzberger B, Kees MG. Protein binding characteristics and pharmacokinetics of ceftriaxone in intensive care unit patients. Br J Clin Pharmacol 2015; 80:525-33. [PMID: 25808018 DOI: 10.1111/bcp.12636] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/19/2015] [Accepted: 03/19/2015] [Indexed: 11/29/2022] Open
Abstract
AIMS The aim of the present study was to assess the pharmacokinetics of total and unbound ceftriaxone in intensive care unit (ICU) patients and its protein binding characteristics. METHODS Twenty patients (m/f 15/5, age 25-86 years, body weight 60-121 kg, APACHE II 7-40, estimated glomerular filtration rate 19-157 ml min(-1) , albumin 11.7-30.1 g l(-1) , total bilirubin <0.1-36.1 mg dl(-1) ) treated with intravenous ceftriaxone were recruited from two ICUs. Timed plasma samples were obtained using an opportunistic study protocol. Ceftriaxone concentrations were determined by high-performance liquid chromatography; unbound concentrations were determined after ultrafiltration using a new method which maintains physiological pH and temperature. The pharmacokinetics was described by a one-compartment model, the protein-binding characteristics by Michaelis-Menten kinetics. RESULTS For total drug, the volume of distribution was 20.2 l (median; interquartile range 15.6-24.5 l), the half-life 14.5 h (10.0-25.5 h) and the clearance 0.96 l h(-1) (0.55-1.28 l h(-1) ). The clearance of unbound drug was 1.91 l h(-1) (1.46-6.20 l h(-1) ) and linearly correlated with estimated glomerular filtration rate (slope 0.85, y-intercept 0.24 l h(-1) , r(2) = 0.70). The unbound fraction was higher in ICU patients (33.0%; 20.2-44.5%) than reported in healthy volunteers, particularly when renal impairment or severe hyperbilirubinaemia was present. In all patients, unbound concentrations during treatment with ceftriaxone 2 g once daily remained above the EUCAST susceptibility breakpoint (≤1 mg l(-1) ) throughout the whole dosing interval. CONCLUSIONS Protein binding of ceftriaxone is reduced and variable in ICU patients due to hypoalbuminaemia, but also to altered binding characteristics. Despite these changes, the pharmacokinetics of unbound ceftriaxone is governed by renal function. For patients with normal or reduced renal function, standard doses are sufficient.
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Affiliation(s)
- Michael Schleibinger
- Department of Internal Medicine I, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Germany
| | - Cathérine L Steinbach
- Department of Anaesthesiology and Intensive Care, Charité Universitätsmedizin Berlin - Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Christoph Töpper
- Department of Anaesthesiology and Intensive Care, Charité Universitätsmedizin Berlin - Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Germany.,Department of Pharmaceutical Biology, University of Regensburg, Universitätsstr. 31, 93053, Regensburg, Germany
| | - Uwe Liebchen
- Department of Internal Medicine I, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Universitätsstr. 31, 93053, Regensburg, Germany
| | - Bernd Salzberger
- Department of Internal Medicine I, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, 93053, Regensburg, Germany
| | - Martin G Kees
- Department of Anaesthesiology and Intensive Care, Charité Universitätsmedizin Berlin - Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Kelchstr. 31, 12169, Berlin, Germany
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Abstract
OBJECTIVES To determine unbound ertapenem concentrations in plasma and to describe the pharmacokinetics of unbound ertapenem in intensive care unit (ICU) patients. PATIENTS AND METHODS For assessing the influence of experimental conditions and for development of the ultrafiltration protocol, plasma from healthy volunteers was used. Concentrations of total and unbound ertapenem were determined by HPLC in 29 plasma samples from six ICU patients treated with 1 g of ertapenem once daily. The concentration-time courses were described by a one-compartment model. Ertapenem binding to albumin was assessed by Michaelis-Menten kinetics in solutions of human serum albumin, in plasma from healthy volunteers and in plasma from ICU patients. RESULTS The unbound fraction (fu) of ertapenem was highly susceptible to pH and temperature during ultrafiltration and was ∼20% in plasma from healthy volunteers at clinically relevant concentrations. In ICU patients, fu was substantially higher (range 30.9%-53.6%). The unbound concentrations of ertapenem exceeded 2 mg/L for 72% (median; range 39%-100%) of the 24 h dosing interval and 0.25 mg/L for 100% (range 79%-100%). The number of binding sites per albumin molecule was 1.22 (95% CI 1.07-1.38) in plasma from healthy volunteers and 0.404 (95% CI 0.158-0.650) in samples from ICU patients. CONCLUSIONS Determination of unbound ertapenem by ultrafiltration is susceptible to experimental conditions. When determined at physiological pH and temperature, fu of ertapenem is 2- to 4-fold higher than previously reported and even higher in ICU patients. Binding studies indicate that hypoalbuminaemia alone does not explain these differences. This issue should be further investigated for its clinical relevance.
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Affiliation(s)
- Uwe Liebchen
- Department of Internal Medicine I, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, 93053 Regensburg, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Franz-Josef-Strauß Allee 11, 93053 Regensburg, Germany Department of Pharmaceutical Biology, University of Regensburg, Universitätsstr. 31, 93053 Regensburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Universitätsstr. 31, 93053 Regensburg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany
| | - Martin G Kees
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universität Berlin, Kelchstr. 31, 12169 Berlin, Germany Department of Anaesthesiology and Intensive Care, Charité University Hospital Berlin - Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
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Kratzer A, Liebchen U, Schleibinger M, Kees MG, Kees F. Determination of free vancomycin, ceftriaxone, cefazolin and ertapenem in plasma by ultrafiltration: Impact of experimental conditions. J Chromatogr B Analyt Technol Biomed Life Sci 2014; 961:97-102. [DOI: 10.1016/j.jchromb.2014.05.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 05/07/2014] [Accepted: 05/08/2014] [Indexed: 10/25/2022]
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