β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value
OBJECTIVE:. β-lactams are the cornerstone of empiric and targeted antibiotic therapy for critically ill patients. Recently, there have been calls to use β-lactam therapeutic drug monitoring (TDM) within 24–48 hours after the initiation of therapy in critically ill patients. In this article, we revie...
| Main Authors: | , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Wolters Kluwer
2022-07-01
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| Series: | Critical Care Explorations |
| Online Access: | http://journals.lww.com/10.1097/CCE.0000000000000726 |
| _version_ | 1811288026400161792 |
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| author | Thomas J. Dilworth, PharmD Lucas T. Schulz, PharmD Scott T. Micek, PharmD Marin H. Kollef, MD Warren E. Rose, PharmD |
| author_facet | Thomas J. Dilworth, PharmD Lucas T. Schulz, PharmD Scott T. Micek, PharmD Marin H. Kollef, MD Warren E. Rose, PharmD |
| author_sort | Thomas J. Dilworth, PharmD |
| collection | DOAJ |
| description | OBJECTIVE:. β-lactams are the cornerstone of empiric and targeted antibiotic therapy for critically ill patients. Recently, there have been calls to use β-lactam therapeutic drug monitoring (TDM) within 24–48 hours after the initiation of therapy in critically ill patients. In this article, we review the dynamic physiology of critically ill patients, β-lactam dose response in critically ill patients, the impact of pathogen minimum inhibitory concentration (MIC) on β-lactam TDM, and pharmacokinetics in critically ill patients. Additionally, we highlight available clinical data to better inform β-lactam TDM for critically ill patients.
DATA SOURCES:. We retrospectively analyzed patients admitted for sepsis or septic shock at a single academic medical center who were treated with β-lactam antibiotics.
STUDY SELECTION:. Indexed studies in PubMed in English language were selected for review on topics relative to critical care physiology, β-lactams, pharmacokinetics/pharmacodynamics, TDM, and antibiotic susceptibility.
DATA EXTRACTION:. We reviewed potentially related studies on β-lactams and TDM and summarized their design, patients, and results. This is a synthetic, nonsystematic, review.
DATA SYNTHESIS:. In the retrospective analysis of patients treated with β-lactam antibiotics, approximately one-third of patients received less than 48 hours of β-lactam therapy. Of those who continued beyond 48 hours, only 13.7% had patient-specific factors (augmented renal clearance, fluid overload, morbid obesity, and/or surgical drain), suggesting a potential benefit of β-lactam TDM.
CONCLUSIONS:. These data indicate that a strategy of comprehensive β-lactam TDM for critically ill patients is unwarranted as it has not been shown yet to improve patient-oriented outcomes. This review demonstrates that β-lactam TDM in the ICU, while laudable, layers ambiguous β-lactam exposure thresholds upon uncertain/unknown MIC data within a dynamic, unpredictable patient population for whom TDM results will not be available fast enough to significantly affect care. Judicious, targeted TDM for those with risk factors for β-lactam over- or underexposure is a better approach but requires further study. Clinically, choosing the correct antibiotic and dosing β-lactams aggressively, which have a wide therapeutic index, to overcome critical illness factors appears to give critically ill patients the best likelihood of survival. |
| first_indexed | 2024-04-13T03:28:48Z |
| format | Article |
| id | doaj.art-dbec365f4e5b4cd384caeda2d220cd69 |
| institution | Directory Open Access Journal |
| issn | 2639-8028 |
| language | English |
| last_indexed | 2024-04-13T03:28:48Z |
| publishDate | 2022-07-01 |
| publisher | Wolters Kluwer |
| record_format | Article |
| series | Critical Care Explorations |
| spelling | doaj.art-dbec365f4e5b4cd384caeda2d220cd692022-12-22T03:04:34ZengWolters KluwerCritical Care Explorations2639-80282022-07-0147e072610.1097/CCE.0000000000000726202207000-00007β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical ValueThomas J. Dilworth, PharmD0Lucas T. Schulz, PharmD1Scott T. Micek, PharmD2Marin H. Kollef, MD3Warren E. Rose, PharmD41 Department of Pharmacy Services, Advocate Aurora Health, Milwaukee, WI.2 Department of Pharmacy Services, UW Health, Madison, WI.3 Center for Health Outcomes Research and Education, University of Health Sciences and Pharmacy, St. Louis, MO.5 Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO.6 School of Pharmacy, University of Wisconsin-Madison, Madison, WI.OBJECTIVE:. β-lactams are the cornerstone of empiric and targeted antibiotic therapy for critically ill patients. Recently, there have been calls to use β-lactam therapeutic drug monitoring (TDM) within 24–48 hours after the initiation of therapy in critically ill patients. In this article, we review the dynamic physiology of critically ill patients, β-lactam dose response in critically ill patients, the impact of pathogen minimum inhibitory concentration (MIC) on β-lactam TDM, and pharmacokinetics in critically ill patients. Additionally, we highlight available clinical data to better inform β-lactam TDM for critically ill patients. DATA SOURCES:. We retrospectively analyzed patients admitted for sepsis or septic shock at a single academic medical center who were treated with β-lactam antibiotics. STUDY SELECTION:. Indexed studies in PubMed in English language were selected for review on topics relative to critical care physiology, β-lactams, pharmacokinetics/pharmacodynamics, TDM, and antibiotic susceptibility. DATA EXTRACTION:. We reviewed potentially related studies on β-lactams and TDM and summarized their design, patients, and results. This is a synthetic, nonsystematic, review. DATA SYNTHESIS:. In the retrospective analysis of patients treated with β-lactam antibiotics, approximately one-third of patients received less than 48 hours of β-lactam therapy. Of those who continued beyond 48 hours, only 13.7% had patient-specific factors (augmented renal clearance, fluid overload, morbid obesity, and/or surgical drain), suggesting a potential benefit of β-lactam TDM. CONCLUSIONS:. These data indicate that a strategy of comprehensive β-lactam TDM for critically ill patients is unwarranted as it has not been shown yet to improve patient-oriented outcomes. This review demonstrates that β-lactam TDM in the ICU, while laudable, layers ambiguous β-lactam exposure thresholds upon uncertain/unknown MIC data within a dynamic, unpredictable patient population for whom TDM results will not be available fast enough to significantly affect care. Judicious, targeted TDM for those with risk factors for β-lactam over- or underexposure is a better approach but requires further study. Clinically, choosing the correct antibiotic and dosing β-lactams aggressively, which have a wide therapeutic index, to overcome critical illness factors appears to give critically ill patients the best likelihood of survival.http://journals.lww.com/10.1097/CCE.0000000000000726 |
| spellingShingle | Thomas J. Dilworth, PharmD Lucas T. Schulz, PharmD Scott T. Micek, PharmD Marin H. Kollef, MD Warren E. Rose, PharmD β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value Critical Care Explorations |
| title | β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value |
| title_full | β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value |
| title_fullStr | β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value |
| title_full_unstemmed | β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value |
| title_short | β-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: Weighing the Challenges and Opportunities to Assess Clinical Value |
| title_sort | β lactam therapeutic drug monitoring in critically ill patients weighing the challenges and opportunities to assess clinical value |
| url | http://journals.lww.com/10.1097/CCE.0000000000000726 |
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