Intravenous Antibiotics in the Management of H. pylori Infection: A Systematic Review.

Background: Helicobacter pylori is implicated in the development of gastritis, ulcers, and various gastric cancers, representing significant morbidity, mortality, and healthcare spending. Patients with H. pylori infection have traditionally been treated with oral antibiotics, however, oral therapy is not feasible in all clinical situations. We examined the available evidence supporting the use of intravenous (IV) antibiotics in H. pylori. Methods: This systematic review was carried out by reviewing multiple electronic databases: MEDLINE, CENTRAL, EMBASE, CINAHL, Clinicaltrials.org, and the World Health Organization (WHO) database of clinical trials. Articles published from database inception until February 12, 2023 that discussed the use of IV antibiotics in H. pylori management were included. Results: The search strategy identified 978 studies, with 11 meeting the inclusion criteria. The results demonstrate that there is a lack of robust trials examining the use of IV antibiotics in H. pylori management. Many trials demonstrated that IV antibiotics were safe and efficacious but the results are limited by inconsistencies in the year and geographic location trials were conducted, the IV and oral antibiotic regimens, and the duration of therapy. Conclusions: IV antibiotics appear to be a feasible therapeutic alternative in the management of H. pylori and can be considered, especially in patient populations where oral therapy is contraindicated.

Pattern of acquisition of hospital-associated pathogens in the ICU of an academic tertiary care hospital.

BACKGROUND: Among hospitalized patients, a 48-hour window from time of hospitalization defines nosocomial infections and guides empiric antibiotic selection. This time frame may lead to overuse of broad-spectrum antibiotics. Our primary objective was to determine the earliest and median time since hospital admission to acquire antibiotic-resistant pathogens among patients admitted to the intensive care unit (ICU) of an academic, tertiary care hospital. METHODS: Retrospective chart review was conducted for adult patients admitted to the ICU from home or another hospital within the same health authority in 2018, to identify the time to acquisition of hospital-associated pathogens: methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales, non-ESBL ceftriaxone-resistant Enterobacterales, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia. Patients transferred from hospitals outside the health authority, admitted to ICU after 14 days of hospitalization, who were solid organ or bone marrow transplant recipients, or who were otherwise immunocompromised were excluded. RESULTS: In 2018, 1,343 patients were admitted to this ICU; 820 met the inclusion criteria. Of these, 121 (14.76%) acquired a hospital-associated pathogen in the ICU. The probability of isolating a hospital-associated pathogen by 48 hours of hospital admission was 3%. The earliest time to isolate any of these pathogens was 29 hours, and the median was 9 days (interquartile range [IQR] 3.8-15.6 days). CONCLUSIONS: Most patients (85.3%) in this ICU never acquired a hospital-associated pathogen. The median time to acquire a hospital-associated pathogen among the remaining patients suggests that initiating empiric broad-spectrum antibiotics on the basis of a 48-hour threshold may be premature.

HISTORIQUE : Chez les patients hospitalisés, une fenêtre de 48 heures après le moment de l'hospitalisation définit les infections nosocomiales et oriente la sélection d'antibiotiques empiriques. Cette période peut favoriser la surutilisation d'antibiotiques à large spectre. L'objectif primaire de l'étude visait à déterminer la période la plus courte et la période médiane à compter de l'admission pour que les patients admis en soins intensifs à partir d'un hôpital universitaire de soins tertiaires contractent des agents pathogènes antibiorésistants. MÉTHODOLOGIE: Les chercheurs ont procédé à un examen rétrospectif des dossiers des patients adultes admis en soins intensifs à partir de la maison ou d'un autre hôpital de la même autorité sanitaire en 2018, afin de déterminer la période avant de contracter des agents pathogènes associés au milieu hospitalier : Staphylococcus aureus résistant à la méthicilline, entérocoque résistant à la vancomycine, Enterobacterales producteurs de bêta-lactamases à spectre élargi (BLSE), Enterobacterales résistant à la ceftriaxine non producteurs de BLSE, Pseudomonas aeruginosa et Stenotrophomonas maltophilia. Ont été exclus les patients transférés d'un hôpital hors de l'autorité sanitaire, admis en soins intensifs plus de 14 jours après l'hospitalisation, receveurs d'un organe plein ou de moelle osseuse ou autrement immunodéprimés. RÉSULTATS: En 2018, 1 343 patients ont été admis en soins intensifs, dont 820 respectaient les critères d'inclusion. De ce nombre, 121 (14,67 %) ont contracté un agent pathogène en soins intensifs. La probabilité d'isoler un tel agent dans les 48 heures suivant l'admission en milieu hospitalier s'élevait à 3 %. Ces agents pathogènes ont été isolés au plus tôt 29 heures après l'hospitalisation, et au bout d'une période médiane de neuf jours (plage interquartile [PIQ] 3,8 à 15,6 jours). CONCLUSIONS: La plupart des patients (85,3%) de cette unité de soins intensifs n'ont jamais contracté d'agent pathogène associé au milieu hospitalier. Selon la période médiane avant d'acquérir un tel agent pathogène chez les autres patients, il serait prématuré d'entreprendre une antibiothérapie à large spectre au seuil de 48 heures.

Evaluation of tranexamic acid in trauma patients: A retrospective quantitative analysis.

INTRODUCTION: Tranexamic acid (TXA) has been shown to decrease mortality in adult trauma patients with or at significant risk of hemorrhage when administered within 3 h of injury. The use and appropriateness of TXA in adult trauma patients presenting to Royal Columbian Hospital (RCH) was investigated. METHODS: This retrospective chart review utilized the British Columbia Trauma Registry to identify 100 consecutive trauma patients that presented to the emergency department at RCH between April 2012 to June 2015 and met the following indications for TXA: systolic blood pressure <90 mm Hg and/or heart rate >110 bpm and presentation within 8 h of injury. Primary outcomes included: percentage that met indications for TXA, received TXA according to the CRASH-2 protocol, received a pre-hospital dose, and received TXA ≤1, >1 to ≤3, or >3 h from injury. RESULTS: During the given time period, 117 subjects (2.7%) met indications for TXA. 67 patients (57%) received TXA in any dose, with 10 subjects (8.5%) receiving TXA according to the CRASH-2 protocol. Of the 67 patients who received any TXA, 76% did so ≤3 h. 22 patients (19%) received TXA as a pre-hospital dose. CONCLUSIONS: <10% of adult trauma patients that met the indication for TXA received it according to the CRASH-2 protocol. Of those patients that received TXA, 76% did so within 3 h. Further inquiry to identify reasons trauma patients are not receiving TXA as well as quality improvement initiatives in trauma care are required. LEVEL OF EVIDENCE: III STUDY TYPE: Therapeutic.

Penetration of Vancomycin into the Cerebrospinal Fluid: A Systematic Review.

INTRODUCTION: Infectious disease and pharmacokinetic textbooks indicate that vancomycin has poor penetration into the central nervous system due to its hydrophilic nature and high molecular weight. Recent literature suggests that penetration of vancomycin into cerebrospinal fluid (CSF) is higher than previously reported; therefore, we conducted a systematic review to assess the penetration of vancomycin into CSF. METHODS: We searched the MEDLINE, EMBASE, and CENTRAL electronic databases for English-language human studies evaluating serum and CSF concentrations of intravenous vancomycin. RESULTS: In 13 identified studies, the CSF-to-serum ratio of vancomycin varied from 0.00 to 0.81. CSF penetration ranged 0.06-0.81 in patients with meningitis, 0.05-0.17 in ventriculitis, 0.00-0.36 in other infections, and 0-0.13 in patients without infection. Despite variable CSF penetration, 83% of patients with meningitis and 100% of patients with ventriculitis achieved clinical cure. No factor predicted vancomycin CSF penetration. CONCLUSION: Contrary to prior belief, studies included in our review did not show universally low penetration of vancomycin into CSF. CSF vancomycin levels were variable and did not predict clinical cure.

Assessment of clinical pharmacy interventions in the intensive care unit.

BACKGROUND: Clinical pharmacy services have been shown to reduce adverse drug events and health care costs. However, few studies have assessed their effect on patient outcomes in the intensive care unit (ICU). OBJECTIVE: To describe characteristics of ICU patients with documented pharmacist interventions and to evaluate the relationships between patients' complexity level and pharmacists' interventions and between pharmacists' interventions and mortality rate. METHODS: Inpatient records of admissions between January 1, 2004, and March 31, 2007, were analyzed to identify the presence of clinical pharmacy notes (CPNs). The characteristics of patients with and without CPNs were compared using descriptive statistics. For primary analysis of the association between patient complexity level and presence of CPNs, logistic regression modelling was performed to adjust for potential confounding. Logistic regression was also used to explore the possible association between CPNs and mortality. Finally, mortality analysis was carried out for patients with and without CPNs, with matching by complexity level. RESULTS: The main study cohort comprised 1561 patients: 333 (21.3%) with CPNs and 1228 (78.7%) with no CPNs. A greater proportion of those with a CPN had the highest complexity level: 295 (88.6%) of those with CPNs versus 660 (53.7%) of those with no CPNs. After adjustment for age and sex, the odds ratio for having a CPN among patients with complexity level 4 (relative to patients with lower complexity levels) was 8.20 (95% confidence interval 5.44-12.38). Mortality rates were not significantly different between the 2 groups: 26.7% (89/333) among patients with CPNs and 27.9% (343/1228) among those without CPNs (p = 0.66). After adjustment for age, sex, complexity level, and length of stay in the ICU, the presence of a CPN was not significantly associated with mortality. Mortality rates in the matched cohort (n = 1078) were also similar between patients with and without CPNs (89/333 [26.7%] and 226/745 [30.3%], respectively; p = 0.23), and the presence of a CPN was not significantly associated with mortality after adjustments for potential confounding factors. CONCLUSION: Documenting clinical pharmacy activities is essential for assessing pharmacists' impact on patient outcomes. These data suggest that ICU pharmacists prioritize clinical activities to care for the sickest patients.

CONTEXTE: Il a été montré que les services de pharmacie clinique réduisaient les événements indésirables liés aux médicaments et les coûts de soins de santé. En revanche, peu d'études ont évalué leurs effets sur les résultats thérapeutiques chez les patients des unités de soins intensifs (USI). OBJECTIF: Décrire les caractéristiques des patients des USI pour lesquels les pharmaciens avaient consignés des interventions et évaluer les liens entre le niveau de complexité de l'état des patients et les interventions des pharmaciens et entre les interventions des pharmaciens et le taux de mortalité. MÉTHODES: Les dossiers des patients hospitalisés entre le 1er janvier 2004 et le 31 mars 2007 ont été analysés à la recherche de notes de pharmaciens cliniciens (NPC). Les caractéristiques des patients dont le dossier comportait des NPC et de ceux dont le dossier n'en comportait pas ont été comparées au moyen de statistiques descriptives. L'analyse primaire de l'association entre le niveau de complexité de l'état des patients et la présence de NPC a été réalisée au moyen d'un modèle de régression logistique pour compenser les facteurs de confusion potentiels. Ce modèle a aussi été utilisé pour évaluer l'association possible entre les NPC et la mortalité. En dernier lieu, une analyse de mortalité a comparé les patients dont le dossier comportait des NPC à ceux dont le dossier n'en comportait pas, avec un appariement du niveau de complexité. RÉSULTATS: La principale cohorte de l'étude comptait 1561 patients : 333 (21,3 %) dont le dossier comportait des NPC et 1228 (78,7 %) dont le dossier n'en comportait pas. Une plus grande proportion des patients dont le dossier comportait des NPC présentaient le plus haut niveau de complexité : 295 (88,6 %) de ceux avec des NPC contre 660 (53,7 %) de ceux sans NPC. Après ajustement pour l'âge et le sexe, le risque relatif approché de NPC chez les patients présentant un niveau de complexité 4 (par rapport aux patients présentant un niveau de complexité moindre) était de 8,20 (intervalle de confiance à 95 % : 5,44 ­ 12,38). Les taux de mortalité n'étaient pas significativement différents entre les deux groupes : 26,7 % (89/333) chez les patients avec NPC et 27,9 % (343/1228) chez les patients sans NPC (p = 0,66). Après ajustement pour l'âge, le sexe, le niveau de complexité et la durée du séjour à l'USI, la présence d'une NPC au dossier n'était pas associée de façon significative à la mortalité. Les taux de mortalité au sein de la cohorte appariée (n = 1078) étaient également similaires entre les patients avec NPC et ceux sans NPC : respectivement 89/333 (26,7 %) et 226/745 (30,3 %) (p = 0,23); la présence d'une NPC n'a pas été associée de façon significative à la mortalité après ajustements pour les facteurs de confusion potentiels. CONCLUSION: La consignation des activités de pharmacie clinique est essentielle à l'évaluation de l'influence des pharmaciens sur les résultats cliniques pour les patients. Ces données suggèrent que les pharmaciens des USI accordent la priorité aux activités cliniques destinées aux soins des patients les plus malades. [Traduction par l'éditeur].

Validity Evidence for FASTHUG-MAIDENS, a Mnemonic for Identifying Drug-Related Problems in the Intensive Care Unit.

BACKGROUND: The mnemonic FASTHUG (Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head of bed elevation, stress Ulcer prophylaxis, Glucose control) was developed by intensive care unit (ICU) physicians to ensure that key aspects of care are addressed during each patient encounter. Because this tool does not specifically target pharmacotherapy assessments, a modified version, FASTHUG-MAIDENS, was created, by changing the H to mean Hypoactive or Hyperactive delirium and adding M for Medication reconciliation; A for Antibiotics or Anti-infectives; I for Indications for medications; D for drug Dosing; E for Electrolytes, hematology, and other laboratory tests; N for No drug interactions, allergies, duplication, or side effects; and S for Stop dates. OBJECTIVE: To validate the use of FASTHUG-MAIDENS as a tool for identifying drug-related problems (DRPs) in the ICU. METHODS: This randomized, prospective validation study took place between January and May 2011 in the ICUs of 4 hospitals: 2 community-level ICUs and 2 tertiary referral ICUs. Each ICU had a dedicated ICU pharmacist and one or more pharmacy residents completing an ICU rotation as part of their pharmacy practice residency (total of 6 residents). The 6 pharmacy residents were randomly assigned to assess patients admitted to the ICU using FASTHUG-MAIDENS or standard monitoring practice. The mean proportion of DRPs per patient encounter identified by the residents (relative to DRPs identified by the ICU pharmacists) was the primary outcome, and the proportion of total DRPs identified in each group was assessed as a secondary end point. RESULTS: Pharmacy residents using the FASTHUG-MAIDENS mnemonic identified a significantly greater mean proportion of DRPs per patient encounter (73.2% versus 52.4%, p = 0.008) and a greater proportion of total DRPs (77.1% versus 52.5%, p < 0.001) than those assessing patients according to standard monitoring practice. CONCLUSION: In this sample, the mnemonic FASTHUG-MAIDENS was a useful tool to facilitate the capture of DRPs by pharmacy residents working in the ICU.

CONTEXTE: Le code mnémonique anglais FASTHUG (Feeding [alimentation], Analgesia [analgésie], Sedation [sédation], Thromboembolic prophylaxis [prophylaxie thromboembolique], Head of bed elevation [élévation de la tête du lit], stress Ulcer prophylaxis [prophylaxie des ulcères de stress], Glucose control [régulation de la glycémie]) a été imaginé par des médecins intensivistes pour s'assurer que certains aspects clés des soins sont pris en compte pour chaque consultation avec un patient. Comme cet outil ne vise pas spécifiquement les évaluations pharmacothérapeutiques, une version modifiée, FASTHUG-MAIDENS, a été créée, où l'on a remplacé le sens du H par Hypoactive or Hyperactive delirium (délire hypoactif ou hyperactif) et ajouté MAIDENS : Medication reconciliation (bilan comparatif des médicaments); Antibiotics or Anti-infectives (antibiotiques ou anti-infectieux); Indications for medications (indications des médicaments); drug Dosing (posologie des médicaments); Electrolytes, hematology and other laboratory tests (électrolytes, hématologie et autres épreuves de laboratoire); No drug interactions, allergies, duplication, or side effects (absence d'interactions médicamenteuses, d'allergies, de chevauchement ou d'effets secondaires); et Stop dates (dates de fin). OBJECTIF: Valider l'emploi du code mnémonique FASTHUG-MAIDENS comme outil pour dépister les problèmes pharmacothérapeutiques à l'unité des soins intensifs (USI). MÉTHODES: Cette étude de validation aléatoire et prospective a été menée entre janvier et mai 2011 dans les USI de quatre hôpitaux : deux USI de niveau communautaire et deux autres de référence de niveau tertiaire. Chaque USI possédait un pharmacien attitré et au moins un résident en pharmacie complétant un stage à l'USI dans le cadre de leur résidence en pratique pharmaceutique (pour un total de six résidents). Les six résidents en pharmacie ont été assignés au hasard pour évaluer les patients admis à l'USI au moyen du code FASTHUG-MAIDENS ou d'une méthode de suivi standard. Le pourcentage de problèmes pharmacothérapeutiques par consultation avec un patient cernés par les résidents (comparativement à ceux constatés par les pharmaciens intensivistes) était le principal paramètre d'évaluation et le pourcentage de problèmes pharmacothérapeutiques totaux relevés dans chaque groupe était le paramètre d'évaluation secondaire. RÉSULTATS: Les résidents en pharmacie qui ont utilisé le code mnémonique FASTHUG-MAIDENS ont cerné un pourcentage moyen significativement supérieur de problèmes pharmacothérapeutiques par consultation avec un patient (73,2 % contre 52,4 %, p = 0,008) et un pourcentage supérieur de problèmes pharmacothérapeutiques totaux (77,1 % contre 52,5 %, p < 0,001) que ceux qui ont évalué les patients au moyen d'une méthode de suivi standard. CONCLUSION: Dans cet échantillon, le code mnémonique FASTHUG-MAIDENS s'est révélé être un outil utile facilitant la détermination des problèmes pharmacothérapeutiques par les résidents en pharmacie travaillant dans une USI. [Traduction par l'éditeur].

Dexmedetomidine as a procedural sedative for percutaneous tracheotomy: case report and systematic literature review.

Purpose. To describe the successful use of dexmedetomidine as the primary procedural sedative for a percutaneous tracheotomy procedure and to systematically present the supporting literature. Materials and Methods. A Case report of our experience and systematic literature search. PubMed, Embase, and Google Scholar were searched without restriction using the key words dexmedetomidine, percutaneous tracheotomy, and tracheotomy procedure. All relevant published references were retrieved irrespective of their methodological quality. Results. In total, only 3 relevant references were found. These include one small placebo controlled randomized trial and 2 case reports. The randomized, placebo controlled trial enrolled patients already sedated on midazolam and included 64 total patients. The 2 other case reports both described the use of dexmedetomidine as the primary procedural sedative. All of the cases reported the successful completion of the percutaneous tracheotomy without any major complication, but none reported the subjective patient experience. Conclusion. Based on the available published literature and our experience, we suggest that dexmedetomidine be considered for use as the primary procedural sedative for percutaneous tracheotomy procedure. Dexmedetomidine's ability to provide adequate sedation and amnesia, without blunting the respiratory drive and protective reflexes of the patient, may make it an optimal agent in specific cases.

Thrombolytics for cardiac arrest: case report and systematic review of controlled trials.

OBJECTIVE: To describe a successful case involving the use of tenecteplase during cardiac arrest for presumed pulmonary embolism (PE) and to systematically review the evidence from controlled trials supporting the efficacy and safety of thrombolysis during cardiac arrest. CASE SUMMARY: A 48-year-old male presented to the emergency department with an acute onset of shortness of breath that began approximately 2 hours prior to presentation. Prior to undergoing a computed tomography (CT) scan to rule out PE, the patient went into cardiac arrest, with an initial rhythm of pulseless electrical activity at a rate of 140 beats/min. Cardiopulmonary resuscitation (CPR) was initiated and, due to suspected PE, a bolus dose of tenecteplase 50 mg was administered immediately following a single 1-mg dose of epinephrine. CPR was continued and 4 additional 1-mg doses of epinephrine and three 1-mg doses of atropine were given. After 13 minutes of CPR, return of spontaneous circulation (ROSC) was achieved, with a blood pressure of 144/50 mm Hg. After the patient was stabilized, a CT scan demonstrated extensive bilateral pulmonary emboli in most segmental arteries. He was admitted to the intensive care unit where he was sedated, paralyzed, and treated with induced hypothermia for 24 hours. He was discharged from the hospital 2 weeks later on warfarin, with no noted neurologic deficits. DISCUSSION: A systematic search of MEDLINE (1950-August 2010), Embase (1980-August 2010), and Google Scholar (to August 2010) was conducted to identify prospective controlled trials that investigated the use of thrombolytic medications to treat cardiac arrest. Five trials involving 1544 undifferentiated cases of cardiac arrest were found. Overall, some trials reported an improved rate of ROSC following administration of thrombolytics, but there was no overall mortality reduction in any trial. There was, however, an increased risk of bleeding events following administration of a thrombolytic drug. CONCLUSIONS: Controlled trials demonstrate that there is a lack of benefit and potential harm in administering thrombolysis in an undifferentiated patient with cardiac arrest. However, the case we present provides evidence that fibrinolysis may benefit selected patients with cardiac arrest in whom PE is confirmed or in whom there is high index of suspicion of PE.

L-carnitine for acute valproic acid overdose: a systematic review of published cases.

OBJECTIVE: To review the evidence supporting the efficacy and safety of l-carnitine in the management of acute valproic acid overdose. DATA SOURCES: MEDLINE (1950-May 2010), EMBASE (1980-May 2010), and Google Scholar (to May 2010) were searched, using the terms carnitine, valproic acid, and carnitine for valproic acid overdose. Reference citations from identified publications were reviewed. STUDY SELECTION AND DATA EXTRACTION: Full-text publications evaluating the use of l-carnitine for management of valproic acid overdose in humans were sought. All studies, regardless of design, case series, and case reports reporting efficacy or safety endpoints were included. All languages were included. Two authors extracted primary data elements including patient demographics, presenting features, clinical management, and outcomes. DATA SYNTHESIS: Seven articles discussing 8 patients and 1 reporting safety data from records of 674 patients were reviewed. Reports covered both pediatric and adult patients with acute exposures to valproic acid mono- and polydrug overdose who were treated with various regimens of l-carnitine. All patients recovered clinically and no adverse effects were noted. CONCLUSIONS: Published evidence of the efficacy and safety of l-carnitine as an antidote for acute valproic acid overdose is limited. Based on the available evidence, it is reasonable to consider l-carnitine for patients with acute overdose of valproic acid who demonstrate decreased level of consciousness. We recommend intravenous administration of 100 mg/kg once, followed by infusions of 50 mg/kg (to a maximum of 3 g per dose) every 8 hours thereafter, continuing until ammonia levels are decreasing (if they were elevated initially) and the patient demonstrates signs of clinical improvement or until adverse events associated with l-carnitine occur.

Comparing outcomes of meropenem administration strategies based on pharmacokinetic and pharmacodynamic principles: a qualitative systematic review.

OBJECTIVE: To systematically review evidence comparing traditional and alternative dosing strategies for meropenem, based on clinical and pharmacoeconomic outcomes. DATA SOURCES: MEDLINE (1950-September 2009), EMBASE (1980-September 2009), and International Pharmaceutical Abstracts (1970-September 2009) were searched, using the terms meropenem, carbapenems, pharmacodynamics, and pharmacokinetics. Reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: Articles discussing administration of meropenem to adults with normal renal function and comparing at least 2 regimens, 1 of which included the manufacturer-recommended regimen of 0.5 g or 1 g every 8 hours infused over 30 minutes, with clinical, pharmacodynamic, or pharmacoeconomic endpoints, were included. The pharmacodynamic endpoint of interest was percent time that the unbound drug concentration exceeded the minimal inhibitory concentration for a bacterial pathogen. DATA SYNTHESIS: Sixteen studies were reviewed, which included 13 pharmacokinetic and dynamic assessments using Monte Carlo simulations, 5 clinical evaluations, and 3 pharmacoeconomic appraisals. Data on clinical and economic outcomes are largely nonrandomized retrospective analyses and case reports. Meropenem via intermittent prolonged infusion potentially increases the likelihood of achieving pharmacodynamic targets. However, a strong link with improved clinical outcomes is lacking. Smaller doses with shorter intervals appear to provide pharmacodynamic target attainment rates and clinical outcomes similar to those with traditional dosing, with potential pharmacoeconomic benefits. Meropenem via continuous infusion appears to increase the likelihood of achieving pharmacodynamic targets, compared with intermittent infusions. The sparsity of clinical evidence supporting this practice limits its broad application to practice. No studies have formally examined adverse effects with alternative dosing regimens. CONCLUSIONS: Meropenem alternative dosing strategies provide similar pharmacodynamic target attainment rates compared with traditional dosing strategies. Small doses with shorter interval dosing provide additional pharmacoeconomic benefits and similar clinical outcomes. Alternative dosing strategies for meropenem were largely studied in healthy subjects; individuals with pharmacokinetic parameters that differ significantly may be ideal subjects for empiric dose modification.