How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy?

Jamal, Janattul-Ain, Mueller, Bruce A., Choi, Gordon Y. S., Lipman, Jeffrey and Roberts, Jason A. (2015) How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy?. Diagnostic Microbiology and Infectious Disease, 82 1: 92-103. doi:10.1016/j.diagmicrobio.2015.01.013


Author Jamal, Janattul-Ain
Mueller, Bruce A.
Choi, Gordon Y. S.
Lipman, Jeffrey
Roberts, Jason A.
Title How can we ensure effective antibiotic dosing in critically ill patients receiving different types of renal replacement therapy?
Journal name Diagnostic Microbiology and Infectious Disease   Check publisher's open access policy
ISSN 0732-8893
1879-0070
Publication date 2015-05-01
Year available 2015
Sub-type Article (original research)
DOI 10.1016/j.diagmicrobio.2015.01.013
Open Access Status Not yet assessed
Volume 82
Issue 1
Start page 92
End page 103
Total pages 12
Place of publication Philadelphia, PA United States
Publisher Elsevier
Language eng
Subject 2726 Microbiology (medical)
2725 Infectious Diseases
Abstract Determining appropriate antibiotic dosing for critically ill patients receiving renal replacement therapy (RRT) is complex. Worldwide unstandardized and heterogeneous prescribing of RRT as well as altered patient physiology and pathogen susceptibility all cause drug disposition to be much different to that seen in non-critically ill patients. Significant changes to pharmacokinetic parameters, including volume of distribution and clearance, could be expected, in particular, for antibiotics that are hydrophilic with low plasma protein binding and that are usually primarily eliminated by the renal system. Antibiotic clearance is likely to be significantly increased when higher RRT intensities are used. The combined effect of these factors that alter antibiotic disposition is that non-standard dosing strategies should be considered to achieve therapeutic exposure. In particular, an aggressive early approach to dosing should be considered and this may include administration of a 'loading dose', to rapidly achieve therapeutic concentrations and maximally reduce the inoculum of the pathogen. This approach is particularly important given the pharmacokinetic changes in the critically ill as well as the increased likelihood of less susceptible pathogens. Dose individualization that applies knowledge of the RRT and patient factors causing altered pharmacokinetics remains the key approach for ensuring effective antibiotic therapy for these patients. Where possible, therapeutic drug monitoring should also be used to ensure more accurate therapy. A lack of pharmacokinetic data for antibiotics during the prolonged intermittent RRT and intermittent hemodialysis currently limits evidence-based antibiotic dose recommendations for these patients. (C) 2015 Elsevier Inc. All rights reserved.
Formatted abstract
Determining appropriate antibiotic dosing for critically ill patients receiving renal replacement therapy (RRT) is complex. Worldwide unstandardized and heterogeneous prescribing of RRT as well as altered patient physiology and pathogen susceptibility all cause drug disposition to be much different to that seen in non-critically ill patients. Significant changes to pharmacokinetic parameters, including volume of distribution and clearance, could be expected, in particular, for antibiotics that are hydrophilic with low plasma protein binding and that are usually primarily eliminated by the renal system. Antibiotic clearance is likely to be significantly increased when higher RRT intensities are used. The combined effect of these factors that alter antibiotic disposition is that non-standard dosing strategies should be considered to achieve therapeutic exposure. In particular, an aggressive early approach to dosing should be considered and this may include administration of a ‘loading dose’, to rapidly achieve therapeutic concentrations and maximally reduce the inoculum of the pathogen. This approach is particularly important given the pharmacokinetic changes in the critically ill as well as the increased likelihood of less susceptible pathogens. Dose individualization that applies knowledge of the RRT and patient factors causing altered pharmacokinetics remains the key approach for ensuring effective antibiotic therapy for these patients. Where possible, therapeutic drug monitoring should also be used to ensure more accurate therapy. A lack of pharmacokinetic data for antibiotics during the prolonged intermittent RRT and intermittent hemodialysis currently limits evidence-based antibiotic dose recommendations for these patients.
Keyword Pharmacokinetics
Pharmacodynamics
CRRT
SLED
CWH
Q-Index Code C1
Q-Index Status Confirmed Code
Grant ID APP1048652
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2016 Collection
School of Medicine Publications
School of Pharmacy Publications
 
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Citation counts: TR Web of Science Citation Count  Cited 12 times in Thomson Reuters Web of Science Article | Citations
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