Amoxicillin, Beta-lactam Antibiotics, Cefepime, Ceftazidime, Efficacy, Flucloxacillin, Imipenem, Meropenem, Piperacillin, Therapeutic Drug Monitoring, Toxicity
Conditions
Brief summary
Little is known of beta-lactam antibiotics' true therapeutic plasma concentration range. The aims of this study are to define evidence-based, safe and effective upper and lower limits of the plasma concentrations of imipenem, meropenem, amoxicillin, flucloxacillin, piperacillin, ceftazidime and cefepime in patients at increased risk of serious bacterial infections and currently understudied pharmacokinetics (the critically ill, the elderly, and the immunosuppressed). This prospective observational study will include adult patients with suspected or confirmed systemic bacterial infection receiving one of the above-named antibiotics and hospitalized in intensive-care, step-down, or hematology-oncology units of the Geneva University Hospitals (HUG). Eligible patients will be identified via the electronic health record (EHR). Patients receiving traditional intermittent dosing or prolonged infusions will undergo TDM for at least one intermediate (mid-interval) and one trough level at 24 hours (-12 or +48 hours) after the therapy's start. Patients receiving continuous infusions will undergo TDM for at least one steady-state level. Clinical course will be observed for 30 days from the start of the study antibiotic (1st day of study antibiotic =day 1). The primary outcome is incidence of clinical toxicity through day 30 after start of study antibiotic (as stratified by BL trough concentration). Secondary outcomes are listed below.
Detailed description
Little is known of beta-lactam antibiotics' true therapeutic plasma concentration range. The aims of this study are to define evidence-based, safe and effective upper and lower limits of the plasma concentrations of imipenem, meropenem, amoxicillin, flucloxacillin, piperacillin, ceftazidime and cefepime in patients at increased risk of serious bacterial infections and currently understudied pharmacokinetics (the critically ill, the elderly, and the immunosuppressed). This prospective observational study will include adult patients with suspected or confirmed systemic bacterial infection receiving one of the above-named antibiotics and hospitalized in intensive-care, step-down, or hematology-oncology units of the Geneva University Hospitals (HUG). Eligible patients will be identified via the electronic health record (EHR). Patients receiving traditional intermittent dosing or prolonged infusions will undergo TDM for at least one intermediate (mid-interval) and one trough level at 24 hours (-12 or +48 hours) after the therapy's start. Patients receiving continuous infusions will undergo TDM for at least one steady-state level. Clinical course will be observed for 30 days from the start of the study antibiotic (1st day of study antibiotic =day 1). The primary outcome is incidence of clinical toxicity through day 30 after start of study antibiotic (as stratified by BL trough concentration). Secondary outcomes are listed below.
Interventions
OTHERThe study is observational.
The study is observational.
Sponsors
University Hospital, Geneva
University of Geneva, Switzerland
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
\- Hospitalized patients with suspected or confirmed systemic bacterial infection: 1. Receiving either imipenem-cilastatin, meropenem, amoxicillin (±clavulanic acid), flucloxacillin, piperacillin-tazobactam, ceftazidime or cefepime 2. Aged ≥18 years 3. Requiring intensive or intermediate-intensive (step-down) care OR severely immunosuppressed (see definitions)
Exclusion criteria
1. Planned imminent transfer to an outside hospital 2. Poor prognosis with life expectancy \<1 week and/or intended transition to palliative care
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Incidence of clinical toxicity through day 30 after start of study antibiotic | day 30 after start of antibiotic | Incidence of clinical toxicity through day 30 after start of study antibiotic (as stratified by BL trough concentration) |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| clinical response in patients with neutropenic fever: incidence of clinical cure in this subpopulation | day 30 | Clinical response (as in outcome no. 2) in the subgroup of patients with neutropenic fever at the time of BL therapy. (Clinical response is either clinical cure (resolution of symptoms) or clinical failure (lack of improvement in signs and symptoms of infection OR recurrence of signs/symptoms of infection after initial improvement OR death in the 30-day study period considered at least possibly due to the infection).) |
| 30-day mortality attributable to the treated infection | day 30 | 30-day mortality attributable to the treated infection |
| 30-day all-cause mortality | day 30 | 30-day all-cause mortality |
| incidence of reversible toxicity | day 30 | Proportion of adverse events (AE) that are reversible after discontinuation of the relevant BL antibiotic |
| Incidence of Clostridium difficile infection | day 30 | Incidence of Clostridium difficile infection |
| Incidence of clinical toxicity of piperacillin-tazobactam when co-administered with vancomycin | day 30 | Incidence of clinical toxicity of piperacillin-tazobactam (and other beta-lactam antibiotics) when co-administered with vancomycin |
| Clinical response: incidence of clinical cure | day 30 | Clinical response to therapy through day 30 will be measured study-wide. Clinical response is either clinical cure (resolution of symptoms) or clinical failure (lack of improvement in signs and symptoms of infection OR recurrence of signs/symptoms of infection after initial improvement OR death in the 30-day study period considered at least possibly due to the infection). Where the MIC is unavailable, EUCAST epidemiologic cutoffs (ECOFF) will be used; if no organism is isolated, non-species-related breakpoints for targeted organisms (e.g., Pseudomonas aeruginosa) will be used. |
| Incidence of undetectable beta-lactam plasma concentrations | day 30 | Proportion of patients with undetectable beta-lactam trough and/or intermediate concentrations |
| Incidence of off-label prescribing | day 30 | Proportion of patients for whom (a) beta-lactam dosing is off-label according to Swiss recommendations and (b) there are no dosing recommendations (e.g., hemofiltration) |
| The correlation of free versus total flucloxacillin concentrations | day 30 | The correlation of free versus total flucloxacillin concentrations (in a subset of patients, free flucloxacillin plasma levels will also be measured and compared to those of total flucloxacillin). |
| Median intermediate and trough plasma concentrations of tazobactam | through day 30 | In a subset of patients receiving piperacillin/tazobactam, median intermediate and trough plasma concentrations of tazobactam (beta-lactamase inhibitor) in proportion to piperacillin in patients receiving piperacillin-tazobactam |
| Beta-lactam trough concentration/minimal inhibitory concentration (MIC) index | day 1 (±1) | The trough beta-lactam (BL) concentration/minimal inhibitory concentration (MIC) index on day 1 (±1) will be measured in all patients for later correlation analyses with clinical outcomes (clinical success versus failure). |
| Incidence of emergence of resistance | day 30 | Prevalence of emerging resistance to study antibiotics in clinical isolates (from baseline) |
Countries
Switzerland
Outcome results
None listed