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Dejaco A, Dorn C, Paal M, Gruber M, Graf BM, Kees MG. Determination of glomerular filtration rate "en passant" after high doses of iohexol for computed tomography in intensive care medicine-a proof of concept. Front Pharmacol 2024; 15:1346343. [PMID: 38362152 PMCID: PMC10867190 DOI: 10.3389/fphar.2024.1346343] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024] Open
Abstract
Accurate assessment of renal function is of great clinical and scientific importance, as it is an important pharmacokinetic covariate of pivotal drugs. The iohexol clearance is nearly identical to the glomerular filtration rate, but its determination usually requires an intravenous injection and therefore bears intrinsic risks. This motivates to showcase an "en passant" approach to quantification of renal function without additional risk or blood sampling beyond routine care using real-world data. We enrolled 37 intensive care patients who received high doses of iohexol for computed tomography imaging, and quantified series of iohexol plasma concentrations by high-performance liquid chromatography (HPLC-UV). Iohexol clearance was derived by both log-linear regression and nonlinear least squares fitting and compared to glomerular filtration rate estimated by the CKD-EPI-2021 formulas. Nonlinear fitting not only turned out to be more accurate but also more robust in handling the irregularly timed data points. Concordance of iohexol clearance against estimations based on both creatinine and cystatin C showed a slightly higher bias (-3.44 mL/min/1.73 m2) compared to estimations based on creatinine alone (-0.76 mL/min/1.73 m2), but considerably narrower limits of agreement (±42.8 vs. 56 mL/min/1.73 m2) and higher Lin's correlation (0.84 vs. 0.72). In summary, we have demonstrated the feasibility and performance of the "en passant" variant of the iohexol method in intensive care medicine and described a working protocol for its application in clinical practice and pharmacologic studies.
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Affiliation(s)
- Alexander Dejaco
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Michael Paal
- Institute for Laboratory Medicine, Hospital of the University of Munich (LMU), Munich, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard M. Graf
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Martin G. Kees
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
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Kees MG, Bierl K, Verloh N. [Verifying the position of an epidural catheter by computed tomography]. ROFO-FORTSCHR RONTG 2022; 194:1028-1030. [PMID: 35545105 DOI: 10.1055/a-1826-0212] [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] [Indexed: 10/18/2022]
Affiliation(s)
- Martin G Kees
- Department of Anesthesiology, University Hospital Regensburg, Germany
| | - Katharina Bierl
- Department of Anesthesiology, University Hospital Regensburg, Germany
| | - Niklas Verloh
- Department of Radiology, University Hospital Regensburg, Germany.,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Germany
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Dorn C, Petroff D, Stoelzel M, Kees MG, Kratzer A, Dietrich A, Kloft C, Zeitlinger M, Kees F, Wrigge H, Simon P. Perioperative administration of cefazolin and metronidazole in obese and non-obese patients: a pharmacokinetic study in plasma and interstitial fluid. J Antimicrob Chemother 2021; 76:2114-2120. [PMID: 33969405 DOI: 10.1093/jac/dkab143] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/11/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess plasma and tissue pharmacokinetics of cefazolin and metronidazole in obese patients undergoing bariatric surgery and non-obese patients undergoing intra-abdominal surgery. PATIENTS AND METHODS Fifteen obese and 15 non-obese patients received an IV short infusion of 2 g cefazolin and 0.5 g metronidazole for perioperative prophylaxis. Plasma and microdialysate from subcutaneous tissue were sampled until 8 h after dosing. Drug concentrations were determined by HPLC-UV. Pharmacokinetic parameters were calculated non-compartmentally. RESULTS In obese patients (BMI 39.5-69.3 kg/m2) compared with non-obese patients (BMI 18.7-29.8 kg/m2), mean Cmax of total cefazolin in plasma was lower (115 versus 174 mg/L) and Vss was higher (19.4 versus 14.2 L). The mean differences in t½ (2.7 versus 2.4 h), CL (5.14 versus 4.63 L/h) and AUC∞ (402 versus 450 mg·h/L) were not significant. The influence of obesity on the pharmacokinetics of metronidazole was similar (Cmax 8.99 versus 14.7 mg/L, Vss 73.9 versus 51.8 L, t½ 11.9 versus 9.1 h, CL 4.62 versus 4.13 L/h, AUC∞ 116 versus 127 mg·h/L). Regarding interstitial fluid (ISF), mean concentrations of cefazolin remained >4 mg/L until 6 h in both groups, and those of metronidazole up to 8 h in the non-obese group. In obese patients, the mean ISF concentrations of metronidazole were between 3 and 3.5 mg/L throughout the measuring interval. CONCLUSIONS During the time of surgery, cefazolin concentrations in plasma and ISF of subcutaneous tissue were lower in obese patients, but not clinically relevant. Regarding metronidazole, the respective differences were higher, and may influence dosing of metronidazole for perioperative prophylaxis in obese patients.
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Affiliation(s)
- Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany.,Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany
| | - Melanie Stoelzel
- Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
| | - Martin G Kees
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Alexander Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Regensburg, Germany
| | - Arne Dietrich
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Surgery, University of Leipzig, Leipzig, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, Regensburg, Germany
| | - Hermann Wrigge
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
| | - Philipp Simon
- Integrated Research and Treatment Center (IFB) Adiposity Diseases, University of Leipzig, Leipzig, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University of Leipzig Medical Centre, Leipzig, Germany
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Schießer S, Hitzenbichler F, Kees MG, Kratzer A, Lubnow M, Salzberger B, Kees F, Dorn C. Measurement of Free Plasma Concentrations of Beta-Lactam Antibiotics: An Applicability Study in Intensive Care Unit Patients. Ther Drug Monit 2021; 43:264-270. [PMID: 33086362 DOI: 10.1097/ftd.0000000000000827] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The antibacterial effect of antibiotics is linked to the free drug concentration. This study investigated the applicability of an ultrafiltration method to determine free plasma concentrations of beta-lactam antibiotics in ICU patients. METHODS Eligible patients included adult ICU patients treated with ceftazidime (CAZ), meropenem (MEM), piperacillin (PIP)/tazobactam (TAZ), or flucloxacillin (FXN) by continuous infusion. Up to 2 arterial blood samples were drawn at steady state. Patients could be included more than once if they received another antibiotic. Free drug concentrations were determined by high-performance liquid chromatography with ultraviolet detection after ultrafiltration, using a method that maintained physiological conditions (pH 7.4/37°C). Total drug concentrations were determined to calculate the unbound fraction. In a post-hoc analysis, free concentrations were compared with the target value of 4× the epidemiological cut-off value (ECOFF) for Pseudomonas aeruginosa as a worst-case scenario for empirical therapy with CAZ, MEM or PIP/tazobactam and against methicillin-sensitive Staphylococcus aureus for targeted therapy with FXN. RESULTS Fifty different antibiotic treatment periods in 38 patients were evaluated. The concentrations of the antibiotics showed a wide range because of the fixed dosing regimen in a mixed population with variable kidney function. The mean unbound fractions (fu) of CAZ, MEM, and PIP were 102.5%, 98.4%, and 95.7%, with interpatient variability of <6%. The mean fu of FXN was 11.6%, with interpatient variability of 39%. It was observed that 2 of 12 free concentrations of CAZ, 1 of 40 concentrations of MEM, and 11 of 23 concentrations of PIP were below the applied target concentration of 4 × ECOFF for P. aeruginosa. All concentrations of FXN (9 samples from 6 patients) were >8 × ECOFF for methicillin-sensitive Staphylococcus aureus. CONCLUSIONS For therapeutic drug monitoring purposes, measuring total or free concentrations of CAZ, MEM, or PIP is seemingly adequate. For highly protein-bound beta-lactams such as FXN, free concentrations should be favored in ICU patients with prevalent hypoalbuminemia.
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Affiliation(s)
- Selina Schießer
- Departments of Infection Prevention and Infectious Diseases and
| | | | | | | | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg
| | | | - Frieder Kees
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
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Zech N, Seemann M, Luerding R, Doenitz C, Zeman F, Cananoglu H, Kees MG, Hansen E. Neurocognitive Impairment After Propofol With Relevance for Neurosurgical Patients and Awake Craniotomies-A Prospective Observational Study. Front Pharmacol 2021; 12:632887. [PMID: 33679415 PMCID: PMC7930827 DOI: 10.3389/fphar.2021.632887] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/13/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Short-acting anesthetics are used for rapid recovery, especially for neurological testing during awake craniotomy. Extent and duration of neurocognitive impairment are ambiguous. Methods: Prospective evaluation of patients undergoing craniotomy for tumor resection during general anesthesia with propofol (N of craniotomies = 35). Lexical word fluency, digit span and trail making were tested preoperatively and up to 24 h after extubation. Results were stratified for age, tumor localization and hemisphere of surgery. Results in digit span test were compared to 21 patients during awake craniotomies. Results: Word fluency was reduced to 30, 33, 47, and 87% of preoperative values 10, 30, 60 min and 24 h after extubation, respectively. Digit span was decreased to 41, 47, 55, and 86%. Performances were still significantly impaired 24 h after extubation, especially in elderly. Results of digit span test were not worse in patients with left hemisphere surgery. Significance of difference to baseline remained, when patients with left or frontal lesions, i.e., brain areas essential for these tests, were excluded from analysis. Time for trail making was increased by 87% at 1 h after extubation, and recovered within 24 h. In 21 patients undergoing awake craniotomies without pharmacological sedation, digit span was unaffected during intraoperative testing. Conclusion: Selected aspects of higher cognitive functions are compromised for up to 24 h after propofol anesthesia for craniotomy. Propofol and the direct effects of surgical resection on brain networks may be two major factors contributing (possibly jointly) to the observed deficits. Neurocognitive testing was unimpaired in patients undergoing awake craniotomies without sedation.
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Affiliation(s)
- Nina Zech
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Milena Seemann
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Ralf Luerding
- Department of Neurology, University Hospital Regensburg, Regensburg, Germany
| | - Christian Doenitz
- Department of Neurosurgery, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Centre for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - Hamit Cananoglu
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Martin G Kees
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Ernil Hansen
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
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Schneider F, Schulz CM, May M, Schneider G, Ernst C, Jacob M, Zacharowski K, Hachenberg T, Schmidt M, Kretzschmar M, Graf B, Kees MG, Pawlik M, Sander M, Koch C, Zoller M, Heim M. The association of the anesthesiologist’s academic and educational status with self-confidence, self-rated knowledge and objective knowledge in rational antibiotic application. BMC Res Notes 2020; 13:161. [PMID: 32188509 PMCID: PMC7079461 DOI: 10.1186/s13104-020-05010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/11/2020] [Indexed: 11/15/2022] Open
Abstract
Objective This study aimed to investigate the association of anesthetists’ academic and educational status with self-confidence, self-rated knowledge and objective knowledge about rational antibiotic application. Therefore, anesthetists in Germany were asked about their self-confidence, self-rated knowledge and objective knowledge on antibiotic therapy via the Multiinstitutional Reconnaissance of practice with Multiresistant bacteria (MR2) survey. Other analysis from the survey have been published elsewhere, before. Results 361 (52.8%) questionnaires were completed by specialists and built the study group. In overall analysis the Certification in Intensive Care (CIC) was significantly associated with self-confidence (p < 0.001), self-rated knowledge (p < 0.001) and objective knowledge (p = 0.029) about antibiotic prescription. Senior consultant status was linked to self-confidence (p < 0.001) and self-rated knowledge (p = 0.005) but not objective knowledge. Likewise, working on Intensive Care Unit (ICU) during the last 12 months was significantly associated with self-rated knowledge and self-confidence (all p < 0.001). In a logistic regression model, senior consultant status was not associated with any tested influence factor. This analysis unveiled that CIC and working on ICU were more associated with anesthesiologists’ self-confidence and self-rated knowledge than senior consultant status. However, neither of the characteristics was thoroughly associated with objective knowledge.
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Dorn C, Schießer S, Wulkersdorfer B, Hitzenbichler F, Kees MG, Zeitlinger M. Determination of free clindamycin, flucloxacillin or tedizolid in plasma: Pay attention to physiological conditions when using ultrafiltration. Biomed Chromatogr 2020; 34:e4820. [PMID: 32115736 DOI: 10.1002/bmc.4820] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 10/31/2019] [Revised: 02/15/2020] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
Pharmacokinetic/pharmacodynamic indices of anti-infective drugs should be referenced to free drug concentrations. In the present study, clindamycin, flucloxacillin and tedizolid have been determined in human plasma by HPLC-UV. The drugs were separated isocratically within 3-6 min on a C18 column using mixtures of phosphate buffer-acetonitrile of pH 7.1-7.2. Sample treatment for the determination of total drug concentrations in plasma included extraction/back-extraction (clindamycin) or protein precipitation (flucloxacillin, tedizolid). The free drug concentrations were determined after ultrafiltration. An ultrafiltration device with a membrane consisting of regenerated cellulose proved to be suitable for all drugs. Maintaining a physiological pH was crucial for clindamycin, whereas maintaining body temperature was essential for tedizolid. The methods were applied to the analysis of total and free drug concentrations in clinical samples and were sufficiently sensitive for pharmacokinetic studies and therapeutic drug monitoring.
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Affiliation(s)
- Christoph Dorn
- Institute of Pharmacy, University of Regensburg, Regensburg, Germany
| | - Selina Schießer
- Infectious Diseases Unit, University Hospital Regensburg, Regensburg, Germany
| | | | | | - Martin G Kees
- Department of Anaesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Schneider F, Schulz CM, May M, Schneider G, Jacob M, Mutlak H, Pawlik M, Zoller M, Kretzschmar M, Koch C, Kees MG, Burger M, Lebentrau S, Novotny A, Hübler M, Koch T, Heim M. [Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]. Anaesthesist 2020; 69:162-169. [PMID: 32055886 DOI: 10.1007/s00101-020-00736-3] [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: 10/16/2019] [Revised: 12/12/2019] [Accepted: 01/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area. OBJECTIVE This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge. METHODS In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ2-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items. RESULTS The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics. CONCLUSION Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.
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Affiliation(s)
- F Schneider
- Fakultät für Medizin, Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, München, Deutschland. .,Klinik für Anästhesiologie und Intensivmedizin, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - C M Schulz
- Fakultät für Medizin, Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, München, Deutschland
| | - M May
- Urologische Klinik, St. Elisabeth-Klinikum Straubing, Straubing, Deutschland
| | - G Schneider
- Fakultät für Medizin, Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, München, Deutschland
| | - M Jacob
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerzmedizin, Klinikum St. Elisabeth Straubing, Straubing, Deutschland
| | - H Mutlak
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Goethe-Universität, Frankfurt, Deutschland
| | - M Pawlik
- Klinik für Anästhesiologie, Krankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - M Zoller
- Klinik für Anästhesiologie der Universität München, Klinikum der Ludwig-Maximilians-Universität München, München, Deutschland
| | - M Kretzschmar
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Magdeburg A.ö.R., Otto-von-Guericke-Universität Magdeburg, Magdeburg, Deutschland
| | - C Koch
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - M G Kees
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - M Burger
- Urologische Klinik, Caritas St. Josef Krankenhaus, Universität Regensburg, Regensburg, Deutschland
| | - S Lebentrau
- Urologische Klinik, Ruppiner Kliniken GmbH, Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin, Deutschland
| | - A Novotny
- Fakultät für Medizin, Klinik und Poliklinik für Chirurgie, Technische Universität München, München, Deutschland
| | - M Hübler
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - T Koch
- Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - M Heim
- Fakultät für Medizin, Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, München, Deutschland
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Dorn C, Petroff D, Neumann N, Kratzer A, El-Najjar N, Dietrich A, Kloft C, Zeitlinger M, Kees MG, Kees F, Wrigge H, Simon P. Plasma and tissue pharmacokinetics of fosfomycin in morbidly obese and non-obese surgical patients: a controlled clinical trial. J Antimicrob Chemother 2019; 74:2473. [PMID: 31173638 DOI: 10.1093/jac/dkz249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Broeker A, Wicha SG, Dorn C, Kratzer A, Schleibinger M, Kees F, Heininger A, Kees MG, Häberle H. Tigecycline in critically ill patients on continuous renal replacement therapy: a population pharmacokinetic study. Crit Care 2018; 22:341. [PMID: 30558639 PMCID: PMC6296114 DOI: 10.1186/s13054-018-2278-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 08/20/2018] [Accepted: 11/26/2018] [Indexed: 01/03/2023]
Abstract
Background Tigecycline is a vital antibiotic treatment option for infections caused by multiresistant bacteria in the intensive care unit (ICU). Acute kidney injury (AKI) is a common complication in the ICU requiring continuous renal replacement therapy (CRRT), but pharmacokinetic data for tigecycline in patients receiving CRRT are lacking. Methods Eleven patients mainly with intra-abdominal infections receiving either continuous veno-venous hemodialysis (CVVHD, n = 8) or hemodiafiltration (CVVHDF, n = 3) were enrolled, and plasma as well as effluent samples were collected according to a rich sampling schedule. Total and free tigecycline was determined by ultrafiltration and high-performance liquid chromatography (HPLC)-UV. Population pharmacokinetic modeling using NONMEM® 7.4 was used to determine the pharmacokinetic parameters as well as the clearance of CVVHD and CVVHDF. Pharmacokinetic/pharmacodynamic target attainment analyses were performed to explore the potential need for dose adjustments of tigecycline in CRRT. Results A two-compartment population pharmacokinetic (PK) model was suitable to simultaneously describe the plasma PK and effluent measurements of tigecycline. Tigecycline dialysability was high, as indicated by the high mean saturation coefficients of 0.79 and 0.90 for CVVHD and CVVHDF, respectively, and in range of the concentration-dependent unbound fraction of tigecycline (45–94%). However, the contribution of CRRT to tigecycline clearance (CL) was only moderate (CLCVVHD: 1.69 L/h, CLCVVHDF: 2.71 L/h) in comparison with CLbody (physiological part of the total clearance) of 18.3 L/h. Bilirubin was identified as a covariate on CLbody in our collective, reducing the observed interindividual variability on CLbody from 58.6% to 43.6%. The probability of target attainment under CRRT for abdominal infections was ≥ 0.88 for minimal inhibitory concentration (MIC) values ≤ 0.5 mg/L and similar to patients without AKI. Conclusions Despite high dialysability, dialysis clearance displayed only a minor contribution to tigecycline elimination, being in the range of renal elimination in patients without AKI. No dose adjustment of tigecycline seems necessary in CRRT. Trial registration EudraCT, 2012–005617-39. Registered on 7 August 2013. Electronic supplementary material The online version of this article (10.1186/s13054-018-2278-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Broeker
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Bundesstraße 45, 20146, Hamburg, Germany.
| | - C Dorn
- Institute of Pharmacy, University of Regensburg, Universitätstr. 31, 93053, Regensburg, Germany
| | - A Kratzer
- Hospital Pharmacy, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - M Schleibinger
- Department of Orthopaedics and Trauma, Hospital Ingolstadt, Krumenauerstraße 25, 85049, Ingolstadt, Germany
| | - F Kees
- Department of Pharmacology and Toxicology, University of Regensburg, Universitätsstr. 31, 93053, Regensburg, Germany
| | - A Heininger
- Department of Infectious Diseases, Medical Microbiology and Hygiene, Division Hospital and Environmental Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany
| | - M G Kees
- Department of Anesthesiology, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - H Häberle
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
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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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12
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Sartelli M, Weber DG, Ruppé E, Bassetti M, Wright BJ, Ansaloni L, Catena F, Coccolini F, Abu-Zidan FM, Coimbra R, Moore EE, Moore FA, Maier RV, De Waele JJ, Kirkpatrick AW, Griffiths EA, Eckmann C, Brink AJ, Mazuski JE, May AK, Sawyer RG, Mertz D, Montravers P, Kumar A, Roberts JA, Vincent JL, Watkins RR, Lowman W, Spellberg B, Abbott IJ, Adesunkanmi AK, Al-Dahir S, Al-Hasan MN, Agresta F, Althani AA, Ansari S, Ansumana R, Augustin G, Bala M, Balogh ZJ, Baraket O, Bhangu A, Beltrán MA, Bernhard M, Biffl WL, Boermeester MA, Brecher SM, Cherry-Bukowiec JR, Buyne OR, Cainzos MA, Cairns KA, Camacho-Ortiz A, Chandy SJ, Che Jusoh A, Chichom-Mefire A, Colijn C, Corcione F, Cui Y, Curcio D, Delibegovic S, Demetrashvili Z, De Simone B, Dhingra S, Diaz JJ, Di Carlo I, Dillip A, Di Saverio S, Doyle MP, Dorj G, Dogjani A, Dupont H, Eachempati SR, Enani MA, Egiev VN, Elmangory MM, Ferrada P, Fitchett JR, Fraga GP, Guessennd N, Giamarellou H, Ghnnam W, Gkiokas G, Goldberg SR, Gomes CA, Gomi H, Guzmán-Blanco M, Haque M, Hansen S, Hecker A, Heizmann WR, Herzog T, Hodonou AM, Hong SK, Kafka-Ritsch R, Kaplan LJ, Kapoor G, Karamarkovic A, Kees MG, Kenig J, Kiguba R, Kim PK, Kluger Y, Khokha V, Koike K, Kok KYY, Kong V, Knox MC, Inaba K, Isik A, Iskandar K, Ivatury RR, Labbate M, Labricciosa FM, Laterre PF, Latifi R, Lee JG, Lee YR, Leone M, Leppaniemi A, Li Y, Liang SY, Loho T, Maegele M, Malama S, Marei HE, Martin-Loeches I, Marwah S, Massele A, McFarlane M, Melo RB, Negoi I, Nicolau DP, Nord CE, Ofori-Asenso R, Omari AH, Ordonez CA, Ouadii M, Pereira Júnior GA, Piazza D, Pupelis G, Rawson TM, Rems M, Rizoli S, Rocha C, Sakakhushev B, Sanchez-Garcia M, Sato N, Segovia Lohse HA, Sganga G, Siribumrungwong B, Shelat VG, Soreide K, Soto R, Talving P, Tilsed JV, Timsit JF, Trueba G, Trung NT, Ulrych J, van Goor H, Vereczkei A, Vohra RS, Wani I, Uhl W, Xiao Y, Yuan KC, Zachariah SK, Zahar JR, Zakrison TL, Corcione A, Melotti RM, Viscoli C, Viale P. Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA). World J Emerg Surg 2016; 11:33. [PMID: 27429642 PMCID: PMC4946132 DOI: 10.1186/s13017-016-0089-y] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/04/2016] [Indexed: 02/08/2023] Open
Abstract
Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Dieter G. Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Etienne Ruppé
- Genomic Research Laboratory, Geneva University Hospitals, Geneva, Switzerland
| | - Matteo Bassetti
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - Brian J. Wright
- Department of Emergency Medicine and Surgery, Stony Brook University School of Medicine, Stony Brook, NY USA
| | - Luca Ansaloni
- General Surgery Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fausto Catena
- Department of General, Maggiore Hospital, Parma, Italy
| | | | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Raul Coimbra
- Department of Surgery, UC San Diego Medical Center, San Diego, USA
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, CO USA
| | - Frederick A. Moore
- Department of Surgery, Division of Acute Care Surgery, and Center for Sepsis and Critical Illness Research, University of Florida College of Medicine, Gainesville, FL USA
| | - Ronald V. Maier
- Department of Surgery, University of Washington, Seattle, WA USA
| | - Jan J. De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Andrew W. Kirkpatrick
- General, Acute Care, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Ewen A. Griffiths
- General and Upper GI Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Christian Eckmann
- Department of General, Visceral, and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Peine, Germany
| | - Adrian J. Brink
- Department of Clinical microbiology, Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University in Saint Louis, Missouri, USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN USA
| | - Rob G. Sawyer
- Department of Surgery, University of Virginia Health System, Charlottesville, VA USA
| | - Dominik Mertz
- Departments of Medicine, Clinical Epidemiology and Biostatistics, and Pathology and Molecular Medicine, McMaster University, Hamilton, ON Canada
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Anand Kumar
- Section of Critical Care Medicine and Section of Infectious Diseases, Department of Medicine, Medical Microbiology and Pharmacology/Therapeutics, University of Manitoba, Winnipeg, MB Canada
| | - Jason A. Roberts
- Australia Pharmacy Department, Royal Brisbane and Womens’ Hospital; Burns, Trauma, and Critical Care Research Centre, Australia School of Pharmacy, The University of Queensland, Brisbane, QLD Australia
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Richard R. Watkins
- Department of Internal Medicine, Division of Infectious Diseases, Akron General Medical Center, Northeast Ohio Medical University, Akron, OH USA
| | - Warren Lowman
- Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Brad Spellberg
- Division of Infectious Diseases, Los Angeles County-University of Southern California (USC) Medical Center, Keck School of Medicine at USC, Los Angeles, CA USA
| | - Iain J. Abbott
- Department of Infectious Diseases, Alfred Hospital, Melbourne, VIC Australia
| | | | - Sara Al-Dahir
- Division of Clinical and Administrative Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA USA
| | - Majdi N. Al-Hasan
- Department of Medicine, Division of Infectious Diseases, University of South Carolina School of Medicine, Columbia, SC USA
| | | | | | - Shamshul Ansari
- Department of Microbiology, Chitwan Medical College, and Department of Environmental and Preventive Medicine, Oita University, Oita, Japan
| | - Rashid Ansumana
- Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, University of Liverpool, and Mercy Hospital Research Laboratory, Njala University, Bo, Sierra Leone
| | - Goran Augustin
- Department of Surgery, University Hospital Center, Zagreb, Croatia
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | | | - Aneel Bhangu
- Academic Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Marcelo A. Beltrán
- Department of General Surgery, Hospital San Juan de Dios de La Serena, La Serena, Chile
| | | | - Walter L. Biffl
- Department of Surgery, University of Colorado, Denver, CO USA
| | | | - Stephen M. Brecher
- Department of Pathology and Laboratory Medicine, VA Boston HealthCare System, and Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA USA
| | - Jill R. Cherry-Bukowiec
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI USA
| | - Otmar R. Buyne
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Miguel A. Cainzos
- Department of Surgery, Hospital Clínico Universitario, Santiago de Compostela, Spain
| | - Kelly A. Cairns
- Pharmacy Department, Alfred Health, Melbourne, VIC Australia
| | - Adrian Camacho-Ortiz
- Hospital Epidemiology and Infectious Diseases, Hospital Universitario Dr Jose Eleuterio Gonzalez, Monterrey, Mexico
| | - Sujith J. Chandy
- Department of Pharmacology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala India
| | - Asri Che Jusoh
- Department of General Surgery, Kuala Krai Hospital, Kuala Krai, Kelantan Malaysia
| | - Alain Chichom-Mefire
- Department of Surgery and Obstetrics/Gynaecology, Regional Hospital, Limbe, Cameroon
| | - Caroline Colijn
- Department of Mathematics, Imperial College London, London, UK
| | - Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, Colli-Monaldi Hospital, Naples, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Daniel Curcio
- Infectología Institucional SRL, Hospital Municipal Chivilcoy, Buenos Aires, Argentina
| | - Samir Delibegovic
- Department of Surgery, University Clinical Center of Tuzla, Tuzla, Bosnia and Herzegovina
| | - Zaza Demetrashvili
- Department General Surgery, Kipshidze Central University Hospital, Tbilisi, Georgia
| | | | - Sameer Dhingra
- School of Pharmacy, Faculty of Medical Sciences, The University of the West Indies, St. Augustine, Eric Williams Medical Sciences Complex, Uriah Butler Highway, Champ Fleurs, Trinidad and Tobago
| | - José J. Diaz
- Division of Acute Care Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD USA
| | - Isidoro Di Carlo
- Department of Surgical Sciences, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Angel Dillip
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Michael P. Doyle
- Center for Food Safety, Department of Food Science and Technology, University of Georgia, Griffin, GA USA
| | - Gereltuya Dorj
- School of Pharmacy and Biomedicine, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Agron Dogjani
- Department of Surgery, University Hospital of Trauma, Tirana, Albania
| | - Hervé Dupont
- Département d’Anesthésie-Réanimation, CHU Amiens-Picardie, and INSERM U1088, Université de Picardie Jules Verne, Amiens, France
| | - Soumitra R. Eachempati
- Department of Surgery, Division of Burn, Critical Care, and Trauma Surgery (K.P.S., S.R.E.), Weill Cornell Medical College/New York-Presbyterian Hospital, New York, USA
| | - Mushira Abdulaziz Enani
- Department of Medicine, Infectious Disease Division, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Valery N. Egiev
- Department of Surgery, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Mutasim M. Elmangory
- Sudan National Public Health Laboratory, Federal Ministry of Health, Khartoum, Sudan
| | - Paula Ferrada
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Joseph R. Fitchett
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
| | - Gustavo P. Fraga
- Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | | | - Helen Giamarellou
- 6th Department of Internal Medicine, Hygeia General Hospital, Athens, Greece
| | - Wagih Ghnnam
- Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - George Gkiokas
- 2nd Department of Surgery, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Carlos Augusto Gomes
- Department of Surgery, Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Harumi Gomi
- Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Mito, Ibaraki Japan
| | - Manuel Guzmán-Blanco
- Hospital Privado Centro Médico de Caracas and Hospital Vargas de Caracas, Caracas, Venezuela
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defense Health, National Defence University of Malaysia, Kuala Lumpur, Malaysia
| | - Sonja Hansen
- Institute of Hygiene, Charité-Universitätsmedizin Berlin, Hindenburgdamm 27, 12203 Berlin, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany
| | | | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Adrien Montcho Hodonou
- Department of Surgery, Faculté de médecine, Université de Parakou, BP 123 Parakou, Bénin
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Lewis J. Kaplan
- Department of Surgery Philadelphia VA Medical Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Garima Kapoor
- Department of Microbiology, Gandhi Medical College, Bhopal, India
| | | | - Martin G. Kees
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Jakub Kenig
- 3rd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Ronald Kiguba
- Department of Pharmacology and Therapeutics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Peter K. Kim
- Department of Surgery, Albert Einstein College of Medicine and Jacobi Medical Center, Bronx, NY USA
| | - Yoram Kluger
- Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Vladimir Khokha
- Department of Emergency Surgery, City Hospital, Mozyr, Belarus
| | - Kaoru Koike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenneth Y. Y. Kok
- Department of Surgery, The Brunei Cancer Centre, Jerudong Park, Brunei
| | - Victory Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, South Africa
| | - Matthew C. Knox
- School of Medicine, Western Sydney University, Campbelltown, NSW Australia
| | - Kenji Inaba
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Los Angeles County and University of Southern California Medical Center, University of Southern California, Los Angeles, CA USA
| | - Arda Isik
- Department of General Surgery, Erzincan University, Faculty of Medicine, Erzincan, Turkey
| | - Katia Iskandar
- Department of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Rao R. Ivatury
- Department of Surgery, Virginia Commonwealth University, Richmond, VA USA
| | - Maurizio Labbate
- School of Life Science and The ithree Institute, University of Technology, Sydney, NSW Australia
| | - Francesco M. Labricciosa
- Department of Biomedical Sciences and Public Health, Unit of Hygiene, Preventive Medicine and Public Health, UNIVMP, Ancona, Italy
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Rifat Latifi
- Department of Surgery, Division of Trauma, University of Arizona, Tucson, AZ USA
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Ran Lee
- Texas Tech University Health Sciences Center School of Pharmacy, Abilene, TX USA
| | - Marc Leone
- Department of Anaesthesiology and Critical Care, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Yousheng Li
- Department of Surgery, Inling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Stephen Y. Liang
- Division of Infectious Diseases, Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Tonny Loho
- Division of Infectious Diseases, Department of Clinical Pathology, Faculty of Medicine, University of Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Marc Maegele
- Department for Traumatology and Orthopedic Surgery, Cologne Merheim Medical Center (CMMC), University of Witten/Herdecke (UW/H), Cologne, Germany
| | - Sydney Malama
- Health Research Program, Institute of Economic and Social Research, University of Zambia, Lusaka, Zambia
| | - Hany E. Marei
- Biomedical Research Center, Qatar University, Doha, Qatar
| | - Ignacio Martin-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Wellcome Trust-HRB Clinical Research, Department of Clinical Medicine, Trinity Centre for Health Sciences, St James’ University Hospital, Dublin, Ireland
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | - Amos Massele
- Department of Clinical Pharmacology, School of Medicine, University of Botswana, Gaborone, Botswana
| | - Michael McFarlane
- Department of Surgery, Radiology, University Hospital of the West Indies, Kingston, Jamaica
| | - Renato Bessa Melo
- General Surgery Department, Centro Hospitalar de São João, Porto, Portugal
| | - Ionut Negoi
- Department of Surgery, Emergency Hospital of Bucharest, Bucharest, Romania
| | - David P. Nicolau
- Center of Anti-Infective Research and Development, Hartford, CT USA
| | - Carl Erik Nord
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | | | | - Carlos A. Ordonez
- Department of Surgery and Critical Care, Universidad del Valle, Fundación Valle del Lili, Cali, Colombia
| | - Mouaqit Ouadii
- Department of Surgery, Hassan II University Hospital, Medical School of Fez, Sidi Mohamed Benabdellah University, Fez, Morocco
| | | | - Diego Piazza
- Division of Surgery, Vittorio Emanuele Hospital, Catania, Italy
| | - Guntars Pupelis
- Department of General and Emergency Surgery, Riga East University Hospital ‘Gailezers’, Riga, Latvia
| | - Timothy Miles Rawson
- National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, Hammersmith Campus, London, UK
| | - Miran Rems
- Department of General Surgery, Jesenice General Hospital, Jesenice, Slovenia
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, University of Toronto, Toronto, Canada
| | | | - Boris Sakakhushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | | | - Norio Sato
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Helmut A. Segovia Lohse
- II Cátedra de Clínica Quirúrgica, Hospital de Clínicas, Universidad Nacional de Asunción, San Lorenzo, Paraguay
| | - Gabriele Sganga
- Department of Surgery, Catholic University of Sacred Heart, Policlinico A Gemelli, Rome, Italy
| | - Boonying Siribumrungwong
- Department of Surgery, Faculty of Medicine, Thammasat University Hospital, Thammasat University, Pathum Thani, Thailand
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Tan Tock Seng, Singapore
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Rodolfo Soto
- Department of Emergency Surgery and Critical Care, Centro Medico Imbanaco, Cali, Colombia
| | - Peep Talving
- Department of Surgery, North Estonia Medical Center, Tallinn, Estonia
| | - Jonathan V. Tilsed
- Surgery Health Care Group, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Gabriel Trueba
- Institute of Microbiology, Biological and Environmental Sciences College, University San Francisco de Quito, Quito, Ecuador
| | - Ngo Tat Trung
- Department of Molecular Biology, Tran Hung Dao Hospital, No 1, Tran Hung Dao Street, Hai Ba Trung Dist, Hanoi, Vietnam
| | - Jan Ulrych
- 1st Department of Surgery - Department of Abdominal, Thoracic Surgery and Traumatology, General University Hospital, Prague, Czech Republic
| | - Harry van Goor
- Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Andras Vereczkei
- Department of Surgery, Medical School University of Pécs, Pécs, Hungary
| | - Ravinder S. Vohra
- Nottingham Oesophago-Gastric Unit, Nottingham University Hospitals, Nottingham, UK
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
| | - Yonghong Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, The First Affilliated Hospital, Zhejiang University, Zhejiang, China
| | - Kuo-Ching Yuan
- Trauma and Emergency Surgery Department, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | | | - Jean-Ralph Zahar
- Infection Control Unit, Angers University, CHU d’Angers, Angers, France
| | - Tanya L. Zakrison
- Division of Trauma and Surgical Critical Care, DeWitt Daughtry Family Department of Surgry, University of Miami, Miami, FL USA
| | - Antonio Corcione
- Anesthesia and Intensive Care Unit, AORN dei Colli Vincenzo Monaldi Hospital, Naples, Italy
| | - Rita M. Melotti
- Anesthesiology and Intensive Care Unit, Sant’Orsola University Hospital, Bologna, Italy
| | - Claudio Viscoli
- Infectious Diseases Unit, University of Genoa (DISSAL) and IRCCS San Martino-IST, Genoa, Italy
| | - Perluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant’ Orsola Hospital, University of Bologna, Bologna, Italy
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Steinbach CL, Töpper C, Adam T, Kees MG. Spectrum adequacy of antibiotic regimens for secondary peritonitis: a retrospective analysis in intermediate and intensive care unit patients. Ann Clin Microbiol Antimicrob 2015; 14:48. [PMID: 26541549 PMCID: PMC4635547 DOI: 10.1186/s12941-015-0110-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 06/22/2015] [Accepted: 10/22/2015] [Indexed: 12/20/2022] Open
Abstract
Background
Secondary peritonitis requires surgical source control and adequate antimicrobial treatment. Antimicrobial regimens are usually selected according to local susceptibility data of individual pathogens against single agents, but this neglects both the polymicrobial nature of the infection and the use of combination therapy. We analysed the probability of common regimens to cover all relevant pathogens isolated in one patient (“spectrum adequacy rate”, SAR) in a real-life data set. Methods
Data from 242 patients with secondary peritonitis (88 community acquired, 154 postoperative cases) treated in our IMCU/ICU were obtained retrospectively. The relative frequency of pathogens, resistance rates and the SAR were analysed using the free software R. Results Enterococci were isolated in 47.1 % of all patients, followed by Escherichia coli (42.6 %), other enterobacteriaceae (33.1 %), anaerobes (29.8 %) and Candida spp. (28.9 %). Resistance patterns were consistent with general surveillance data from our hospital. The susceptibility rates and SAR were lower in postoperative than in community acquired cases. The following regimens yielded a SAR > 95 % when enterobacteriaceae only were considered: piperacillin/tazobactam + gentamicin, cefotaxim (only for community acquired cases), cefotaxim + gentamicin, meropenem, tigecycline + gentamicin or tigecycline + ciprofloxaxin. When enterococci were also considered, all betalactam based regimens required combination with vancomycin or linezolid for a SAR > 95 %, whereas TGC based regimens were not compromised. As for Candida spp., the SAR of fluconazole was 81.9–87.5 %. Conclusions This study demonstrates a rational approach to assess the adequacy of antimicrobial regimens in secondary peritonitis, which may help to adjust local guidelines or to select candidate regimens for clinical studies.
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Affiliation(s)
- Cathérine L Steinbach
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin-Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Christoph Töpper
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin-Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.
| | - Thomas Adam
- Labor Berlin GmbH, Department of Microbiology, Clinical Consulting, Sylter Str. 2, 13353, Berlin, Germany.
| | - Martin G Kees
- Department of Anesthesiology and Intensive Care, Charité Universitätsmedizin Berlin-Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.
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Kees MG, Minichmayr IK, Moritz S, Beck S, Wicha SG, Kees F, Kloft C, Steinke T. Population pharmacokinetics of meropenem during continuous infusion in surgical ICU patients. J Clin Pharmacol 2015. [PMID: 26222202 DOI: 10.1002/jcph.600] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 11/09/2022]
Abstract
Continuous infusion of meropenem is a candidate strategy for optimization of its pharmacokinetic/pharmacodynamic profile. However, plasma concentrations are difficult to predict in critically ill patients. Steady-state concentrations of meropenem were determined prospectively during continuous infusion in 32 surgical ICU patients (aged 21-85 years, body weight 55-125 kg, APACHE II 5-29, measured creatinine clearance 22.7-297 mL/min). Urine was collected for the quantification of renal clearance of meropenem and creatinine. Cystatin C was measured as an additional marker of renal function. Population pharmacokinetic models were developed using NONMEM(®) , which described total meropenem clearance and its relationship with several estimates of renal function (measured creatinine clearance CLCR , Cockcroft-Gault formula CLCG , Hoek formula, 1/plasma creatinine, 1/plasma cystatin C) and other patient characteristics. Any estimate of renal function improved the model performance. The strongest association of clearance was found with CLCR (typical clearance = 11.3 L/h × [1 + 0.00932 × (CLCR - 80 mL/min)]), followed by 1/plasma cystatin C; CLCG was the least predictive covariate. Neither age, weight, nor sex was found to be significant. These models can be used to predict dosing requirements or meropenem concentrations during continuous infusion. The covariate CLCR offers the best predictive performance; if not available, cystatin C may provide a promising alternative to plasma creatinine.
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Affiliation(s)
- Martin G Kees
- Department of Anaesthesiology and Intensive Care, Charit, é, Universit, ä, tsmedizin Berlin-Campus Benjamin Franklin, 12200, Berlin, Germany.,Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Iris K Minichmayr
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Stefan Moritz
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), 06120, Halle (Saale), Germany
| | - Stefanie Beck
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Frieder Kees
- Department of Pharmacology, University of Regensburg, 93053, Regensburg, Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, 12169, Berlin, Germany
| | - Thomas Steinke
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), 06120, Halle (Saale), 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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Steinke T, Moritz S, Beck S, Gnewuch C, Kees MG. Estimation of creatinine clearance using plasma creatinine or cystatin C: a secondary analysis of two pharmacokinetic studies in surgical ICU patients. BMC Anesthesiol 2015; 15:62. [PMID: 25927897 PMCID: PMC4426534 DOI: 10.1186/s12871-015-0043-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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: 01/08/2015] [Accepted: 04/21/2015] [Indexed: 01/06/2023] Open
Abstract
Background In ICU patients, glomerular filtration is often impaired, but also supraphysiological values are observed (“augmented renal clearance”, >130 mL/min/1.73 m2). Renally eliminated drugs (e.g. many antibiotics) must be adjusted accordingly, which requires a quantitative measure of renal function throughout all the range of clinically encountered values. Estimation from plasma creatinine is standard, but cystatin C may be a valuable alternative. Methods This was a secondary analysis of renal function parameters in 100 ICU patients from two pharmacokinetic studies on vancomycin and betalactam antibiotics. Estimated clearance values obtained by the Cockcroft-Gault formula (eCLCG), the CKD-EPI formula (eCLCKD-EPI) or the cystatin C based Hoek formula (eCLHoek) were compared with the measured endogenous creatinine clearance (CLCR). Agreement of values was assessed by modified Bland-Altman plots and by calculating bias (median error) and precision (median absolute error). Sensitivity and specificity of estimates to identify patients with reduced (<60 mL/min/1.73 m2) or augmented (>130 mL/min/1.73 m2) CLCR were calculated. Results The CLCR was well distributed from highly compromised to supraphysiological values (median 73.2, range 16.8-234 mL/min/1.73 m2), even when plasma creatinine was not elevated (≤0.8 mg/dL for women, ≤1.1 mg/dL for men). Bias and precision were +13.5 mL/min/1.73 m2 and ±18.5 mL/min/1.73 m2 for eCLCG, +7.59 and ±16.8 mL/min/1.73 m2 for eCLCKD-EPI, and -4.15 and ±12.9 mL/min/1.73 m2 for eCLHoek, respectively, with eCLHoek being more precise than the other two (p < 0.05). The central 95% of observed errors fell between -59.8 and +250 mL/min/1.73 m2 for eCLCG, -83.9 and +79.8 mL/min/1.73 m2 for eCLCKD-EPI, and -103 and +27.9 mL/min/1.73 m2 for eCLHoek. Augmented renal clearance was underestimated by eCLCKD-EPI and eCLHoek. Patients with reduced CLCR were identified with good specificity by eCLCG, eCLCKD-EPI and eCLHoek (0.95, 0.97 and 0.91, respectively), but with less sensitivity (0.55, 0.55 and 0.83). For augmented renal clearance, specificity was 0.81, 0.96 and 0.96, but sensitivity only 0.69, 0.25 and 0.38. Conclusions Normal plasma creatinine concentrations can be highly misleading in ICU patients. Agreement of the cystatin C based eCLHoek with CLCR is better than that of the creatinine based eCLCG or eCLCKD-EPI. Detection and quantification of augmented renal clearance by estimates is problematic, and should rather rely on CLCR. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0043-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Steinke
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Stefan Moritz
- Department of Anaesthesiology and Surgical Intensive Care, University Hospital of Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
| | - Stefanie Beck
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Martini-Str. 52, 20246, Hamburg, Germany.
| | - Carsten Gnewuch
- Institute for Clinical Chemistry and Laboratory Medicine, Regensburg University Medical Center, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| | - Martin G Kees
- Department of Anesthesiology 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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Wicha SG, Kees MG, Solms A, Minichmayr IK, Kratzer A, Kloft C. TDMx: A novel web-based open-access support tool for optimising antimicrobial dosing regimens in clinical routine. Int J Antimicrob Agents 2015; 45:442-4. [DOI: 10.1016/j.ijantimicag.2014.12.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 12/24/2014] [Indexed: 11/28/2022]
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18
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Wicha SG, Haak T, Zink K, Kees F, Kloft C, Kees MG. Population pharmacokinetics and target attainment analysis of moxifloxacin in patients with diabetic foot infections. J Clin Pharmacol 2015; 55:639-46. [DOI: 10.1002/jcph.464] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/15/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Sebastian G. Wicha
- Department of Clinical Pharmacy and Biochemistry; Institute of Pharmacy; Freie Universitaet Berlin; Berlin Germany
| | - Thomas Haak
- Diabetes Center Mergentheim; Bad Mergentheim Germany
| | - Karl Zink
- Diabetes Center Mergentheim; Bad Mergentheim Germany
| | - Frieder Kees
- Department of Pharmacology; University of Regensburg; Regensburg Germany
| | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry; Institute of Pharmacy; Freie Universitaet Berlin; Berlin Germany
| | - Martin G. Kees
- Department of Clinical Pharmacy and Biochemistry; Institute of Pharmacy; Freie Universitaet Berlin; Berlin Germany
- Department of Anesthesiology and Intensive Care; Charité Universitätsmedizin Berlin; 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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Kees MG, Wicha SG, Seefeld A, Kees F, Kloft C. Unbound fraction of vancomycin in intensive care unit patients. J Clin Pharmacol 2013; 54:318-23. [PMID: 24000044 DOI: 10.1002/jcph.175] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [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: 07/28/2013] [Accepted: 08/27/2013] [Indexed: 11/09/2022]
Abstract
Published data on the unbound fraction of vancomycin in patient samples exhibit high variability. In the present study, a robust ultrafiltration method was developed and applied to 102 clinical samples from 22 intensive care unit patients who were treated with continuous infusion of vancomycin. A validated HPLC method was used for determination of total and unbound concentrations. The mean unbound fraction was 67.2% (standard deviation 7.5%, range 47.2-92.1%) and independent of total concentration of vancomycin or of albumin. The unbound fraction was significantly correlated (r = +0.67, P = .0009) with the renally filtered fraction (drug clearance/creatinine clearance), providing functional evidence for the validity of the measurements. Ultrafiltration proved to be susceptible to variations in the experimental conditions such as pH, temperature and centrifugal force. The measured unbound fraction increased from 60% at pH 6 to 100% at pH 9, from 57% at 4°C to 80% at 37°C, and was 76% at 1,000 g compared with 45% at 10,000 g. Lack of standardization may therefore partly explain the variable results reported in the literature.
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Affiliation(s)
- Martin G Kees
- Department of Anesthesiology and Intensive Care, Charité University Hospital Berlin - Campus Benjamin Franklin, Berlin, Germany; Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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Abstract
Antibiotics are used very frequently in critically ill patients as a causal and often life-saving treatment; however, the high density of use of broad spectrum antibiotics contributes to a further deterioration in resistance trends, which makes a rational prescription behavior mandatory. This particularly includes measures which lead to the reduction of antibiotic use, i.e. rigorous indications, targeted de-escalation and limited duration. For optimal efficacy of a necessary treatment the integration of pharmacokinetic and pharmacodynamic principles can be helpful.
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Affiliation(s)
- M G Kees
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin.
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Kees MG, Steinke T, Moritz S, Rupprecht K, Paulus EM, Kees F, Bucher M, Faerber L. Omeprazole impairs the absorption of mycophenolate mofetil but not of enteric-coated mycophenolate sodium in healthy volunteers. J Clin Pharmacol 2011; 52:1265-72. [PMID: 21903891 DOI: 10.1177/0091270011412968] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2 crossover studies, 12 healthy volunteers (6 male/6 female) received a single oral dose of mycophenolate mofetil (MMF) 1000 mg or an equimolar dose of enteric-coated mycophenolate sodium (EC-MPS) 720 mg fasting with and without coadministered omeprazole 20 mg bid. The plasma concentrations of mycophenolic acid (MPA) and of the inactive metabolite mycophenolic acid glucuronide (MPA-G) were measured by high-performance liquid chromatography (HPLC). In addition, dissolution of MMF 500 mg or EC-MPS 360 mg tablets was determined using an USP paddle apparatus in aqueous buffer of pH 1 to 7. The bioavailability of MPA following administration of MMF or EC-MPS was similar except for the time to peak concentration, which was longer in the EC-MPS group. Concomitant treatment with omeprazole lowered significantly C(max) and AUC(12h) of MPA following administration of MMF. The pharmacokinetics of EC-MPS was not affected. Dissolution of MMF in aqueous buffer decreased dramatically at pH above 4.5. The EC-MPS tablet was stable up to pH 5. Above, EC-MPS was quantitatively disintegrated and MPS quantitatively dissolved. There is strong evidence that impaired absorption of MMF with concomitant proton pump inhibitors is due to incomplete dissolution of MMF in the stomach at elevated pH.
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Affiliation(s)
- M G Kees
- Department of Anesthesiology and Intensive Care, Charité University Hospital Berlin-Campus Benjamin Franklin, Hindenburgdamm, Berlin, Germany.
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Kees MG, Hilpert JW, Gnewuch C, Kees F, Voegeler S. Clearance of vancomycin during continuous infusion in Intensive Care Unit patients: correlation with measured and estimated creatinine clearance and serum cystatin C. Int J Antimicrob Agents 2010; 36:545-8. [PMID: 20863668 DOI: 10.1016/j.ijantimicag.2010.07.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2010] [Revised: 07/21/2010] [Accepted: 07/24/2010] [Indexed: 01/05/2023]
Abstract
Vancomycin (VAN) dosing requires adjustment to renal function, which is often estimated using the Cockcroft-Gault formula; however, its precision is poor in Intensive Care Unit (ICU) patients. VAN clearance (CL(Van)) during continuous infusion was prospectively determined in 25 ICU patients [14 male, 11 female; age range 31-82 years; body mass index (BMI) 16.5-41.5 kg/m²; Acute Physiology and Chronic Health Evaluation (APACHE) II score at admission 8-36; creatinine clearance 25-195 mL/min] and its correlation with measured creatinine clearance (CL(Crea)), estimated creatinine clearance using the Cockcroft-Gault formula (CL(CG)) and estimated glomerular filtration rate according to Hoek's formula based on serum cystatin C (GFR(Hoek)) was investigated. The correlation between CL(Van) and CL(Crea) was very good (r²=0.88), but it was rather poor with CL(CG) (r² = 0.37) and was acceptable with GFR(Hoek) (r² = 0.70). For VAN dose adjustments in ICU patients, determination of cystatin C may be an interesting and practical alternative to measured CL(Crea), whereas the Cockcroft-Gault formula should be used with caution.
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Affiliation(s)
- Martin G Kees
- Department of Anesthesiology and Intensive Care, Charité University Hospital Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany.
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Kees MG, Schlotterbeck H, Passemard R, Pottecher T, Diemunsch P. [Ringer solution: osmolarity and composition revisited]. ACTA ACUST UNITED AC 2005; 24:653-5. [PMID: 15876513 DOI: 10.1016/j.annfar.2005.03.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Accepted: 03/31/2005] [Indexed: 11/18/2022]
Abstract
The composition of Ringer solution, a crystalloid fluid that is often used in anaesthesia and intensive care, varies depending on the manufacturer. The knowledge of the actual content in electrolytes and of the characteristics of this fluid is necessary before it is used. We call attention to a certain Ringer solution (Ringer Maco Pharma, Maco Pharma), for which the manufacturer's information about the tonicity and the osmolarity was incorrect. Contrary to what is written on the bag and in the product description (isotonicity, osmolarity of 276.8 mOsm/l), the theoretical osmolarity was 221.4 mOsm/l and the measured osmolality was about 208 mmol/kg, exposing the hypotonic characteristics of this fluid. The use of this product is potentially dangerous in patients with pathologies where the infusion of free water is especially badly supported.
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Affiliation(s)
- M G Kees
- Département d'anesthésie-réanimation, hôpital de Hautepierre, 67000 Strasbourg, France
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Kees MG, Pongratz G, Kees F, Schölmerich J, Straub RH. Via β-adrenoceptors, stimulation of extrasplenic sympathetic nerve fibers inhibits lipopolysaccharide-induced TNF secretion in perfused rat spleen. J Neuroimmunol 2003; 145:77-85. [PMID: 14644033 DOI: 10.1016/j.jneuroim.2003.09.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Using a spleen slice microsuperfusion technique in mice, we have previously characterized the role of norepinephrine (NE) and other neurotransmitters for sympathetic modulation of IL-6 and TNF secretion of splenic macrophages. Since experiments in spleen slices do not reflect the situation of an entire perfused organ, we investigated sympathetic modulation of lipopolysaccharide (LPS)-induced secretion of IL-6 and TNF in perfusion experiments of rat spleen. In an organ bath, perfusion was performed in explanted whole spleens, and catecholamines and cytokines were measured by HPLC and ELISA, respectively. Release of NE depended on stimulation frequency (maximum at 10 Hz). Apart from NE, perfusates also contained significant amounts of dopamine and epinephrine. Furthermore, perfusate epinephrine levels correlated positively with perfusate NE levels (RRank=0.750, p<0.001) but not with plasma epinephrine concentrations. This indicates that epinephrine is a conversion product of sympathetically released NE. Early electrical stimulation of extrasplenic splenic nerves, 20 min after administration of LPS, significantly inhibited TNF secretion. This electrically induced effect was abrogated by simultaneous administration of propranolol (10(-6) M) but it was not influenced by administration of either an alpha1- or alpha2-adrenergic antagonist. Late electrical stimulation of splenic nerves, 2.5 h after administration of LPS, did not change TNF secretion. Interestingly, no influence of early or late sympathetic nerve fiber stimulation on IL-6 secretion was observed. In conclusion, this is the first perfusion study of the entire spleen that demonstrates that early electrical stimulation of sympathetic splenic nerve fibers directly inhibits LPS-induced TNF secretion. This study corroborates the idea that splenic sympathetic nerves are able to inhibit important activators of the innate immune system when stimulation happens very early or even prior to their induction by LPS.
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Affiliation(s)
- Martin G Kees
- Laboratory of Neuro/Endocrino/Immunology, Department of Internal Medicine I, University Hospital, Regensberg 93042, Germany
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