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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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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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Knuth S, Abdelsalam RM, Khayyal MT, Schweda F, Heilmann J, Kees MG, Mair G, Kees F, Jürgenliemk G. Catechol conjugates are in vivo metabolites of Salicis cortex. Planta Med 2013; 79:1489-1494. [PMID: 24146062 DOI: 10.1055/s-0033-1350898] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
After oral administration of 100 mg/kg b. w. (235.8 µmol/kg) salicortin to Wistar rats, peak serum concentrations of 1.43 mg/L (13.0 µM) catechol were detected after 0.5 h in addition to salicylic acid by HPLC-DAD after serum processing with β-glucuronidase and sulphatase. Both metabolites could also be detected in the serum of healthy volunteers following oral administration of a willow bark extract (Salicis cortex, Salix spec., Salicaceae) corresponding to 240 mg of salicin after processing with both enzymes. In humans, the cmax (1.46 mg/L, 13.3 µM) of catechol was reached after 1.2 h. The predominant phase-II metabolite in humans and rats was catechol sulphate, determined by HPLC analysis of serum samples processed with only one kind of enzyme. Without serum processing with glucuronidase and sulphatase, no unconjugated catechol could be detected in human and animal serum samples. As catechol is described as an anti-inflammatory compound, these results may contribute to the elucidation of the mechanism of the action of willow bark extract.
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Affiliation(s)
- Susanne Knuth
- University of Regensburg, Institute of Pharmacy, Department of Pharmaceutical Biology, Regensburg, Germany
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Kees MG, Schaeftlein A, Haeberle HA, Kees F, Kloft C, Heininger A. Population pharmacokinetics and pharmacodynamic evaluation of intravenous and enteral moxifloxacin in surgical intensive care unit patients. J Antimicrob Chemother 2013; 68:1331-7. [PMID: 23463212 DOI: 10.1093/jac/dkt040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To describe the plasma concentration-time profile of moxifloxacin after intravenous and enteral administration in intensive care unit (ICU) patients and to provide a pharmacodynamic (PD) evaluation with regard to pneumonia. PATIENTS AND METHODS Twenty-five adult patients from a cardiothoracic/mixed surgical ICU were enrolled. Moxifloxacin was given as a standard dose (400 mg once daily). Therapy was successfully switched to enteral administration on day 5 in 16 patients. A rich data sampling schedule was performed after intravenous (day 4) and enteral (day 8) administration. Moxifloxacin concentrations were analysed by HPLC. A population pharmacokinetic (PK) model was developed using NONMEM VII. Simulated concentration-time profiles were evaluated for their probability of attaining PK/PD target values relevant for community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP). RESULTS A linear-elimination two-compartment model described the data adequately. Parameter estimates (coefficient of variation of inter-individual variability) were: absorption rate constant, 1.09/h (135%); enteral bioavailability, 76% (20.0%); central volume of distribution, 55.6 L; peripheral volume of distribution, 59.6 L (15.3%); inter-compartmental clearance, 47.7 L/h; and clearance, 11.3 L/h (23.7%). Both intravenously and enterally administered standard-dose moxifloxacin reliably attained the PK/PD target values for pathogens with MICs ≤ 0.25 mg/L for CAP and ≤ 0.125 mg/L for HAP. CONCLUSIONS Drug exposure to moxifloxacin in ICU patients was more variable than in healthy volunteers. The standard dosing provides sufficient drug exposure for treatment of CAP but for HAP it does so only when a highly susceptible pathogen is present. Intravenous/enteral sequential therapy may be considered for cautiously selected cases in ICU patients.
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Affiliation(s)
- Martin Georg Kees
- Department of Anesthesiology and Intensive Care, Charité University Hospital Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 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, 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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