Antimicrobial pharmacokinetics and dosing in critically ill adults receiving prolonged intermittent renal replacement therapy: A systematic review.

Prolonged intermittent renal replacement therapy (PIRRT) is gaining popularity as a renal replacement modality in intensive care units, but there is a relative lack of guidance regarding antimicrobial clearance and dosing when compared with other modalities. The objectives of this systematic review were to: (1) identify and describe the pharmacokinetics (PK) of relevant antimicrobials used in critically ill adults receiving PIRRT, (2) evaluate the quality of evidence supporting these data, and (3) propose dosing recommendations based on the synthesis of these data. A search strategy for multiple databases was designed and executed to identify relevant published evidence describing the PK of antimicrobials used in critically ill adults receiving PIRRT. Quality assessment, evaluation of reporting, and relevant data extraction were conducted in duplicate. Synthesis of PK/pharmacodynamic (PD) outcomes, dosing recommendations from study authors, and physicochemical properties of included antibiotics were assessed by investigators in addition to the quality of evidence to develop dosing recommendations. Thirty-nine studies enrolling 452 patients met criteria for inclusion and provided PK and/or PD data for 20 antimicrobials in critically ill adults receiving PIRRT. Nineteen studies describe both PK and PD outcomes. Vancomycin (12 studies, 171 patients), meropenem (7 studies, 84 patients), and piperacillin/tazobactam (5 studies, 56 patients) were the most frequent antimicrobials encountered. The quality of evidence was deemed strong for 7/20 antimicrobials, and strong dosing recommendations were determined for 9/20 antimicrobials. This systematic review updates and addresses issues of quality in previous systematic reviews on this topic. Despite an overall low quality of evidence, strong recommendations were able to be made for almost half of the identified antimicrobials. Knowledge gaps persist for many antimicrobials, and higher quality studies (i.e., population PK studies with assessment of PD target attainment) are needed to address these gaps.

Therapeutic Drug Monitoring of Vancomycin in Adult Patients with Methicillin-Resistant Staphylococcus aureus Bacteremia or Pneumonia.

BACKGROUND: Vancomycin remains widely used for methicillin-resistant Staphylococcus aureus (MRSA) infections; however, treatment failure rates up to 50% have been reported. At the authors' institution, monitoring of trough concentration is the standard of care for therapeutic drug monitoring of vancomycin. New guidelines support use of the ratio of 24-hour area under the concentration-time curve to minimum inhibitory concentration (AUC24/MIC) as the pharmacodynamic index most likely to predict outcomes in patients with MRSA-associated infections. OBJECTIVES: To determine the discordance rate between trough levels and AUC24/MIC values and how treatment failure and nephrotoxicity outcomes compare between those achieving and not achieving their pharmacodynamic targets. METHODS: This retrospective cohort study involved patients with MRSA bacteremia or pneumonia admitted to the study hospital between March 1, 2014, and December 31, 2018, and treated with vancomycin. Data for trough concentrations were collected, and minimum concentrations (C min) were extrapolated. The AUC24/MIC values were determined using validated population pharmacokinetic models. The C min and AUC24/MIC values were characterized as below, within, or above pharmacodynamic targets (15-20 mg/L and 400-600, respectively). Discordance was defined as any instance where a patient's paired C min and AUC24/MIC values fell in different ranges (i.e., below, within, or above) relative to the target ranges. Predictors of treatment failure and nephrotoxicity were determined using logistic regression. RESULTS: A total of 128 patients were included in the analyses. Of these, 73 (57%) received an initial vancomycin dose less than 15 mg/kg. The discordance rate between C min and AUC24/MIC values was 21% (27/128). Rates of treatment failure and nephrotoxicity were 34% (43/128) and 18% (23/128), respectively. No clinical variables were found to predict discordance. Logistic regression identified initiation of vancomycin after a positive culture result (odds ratio [OR] 4.41, 95% confidence interval [CI] 1.36-14.3) and achievement of target AUC24/MIC after 4 days (OR 3.48, 95% CI 1.39-8.70) as modifiable predictors of treatment failure. CONCLUSIONS: The relationship between vancomycin monitoring and outcome is likely confounded by inadequate empiric or initial dosing. Before any modification of practice with respect to vancomycin monitoring, empiric vancomycin dosing should be optimized.

CONTEXTE: La vancomycine reste largement utilisée contre les infections dues au Staphylococcus aureus méthicillinorésistant (SAMR); cependant, on rapporte des taux d'échec de traitement allant jusqu'à 50 %. Dans l'institution où travaillent les auteurs, la surveillance de la concentration minimale constitue la norme de soins du suivi thérapeutique pharmacologique de la vancomycine. De nouvelles lignes directrices soutiennent l'utilisation du ratio de 24 h de l'aire sous la courbe de concentration-temps à concentration minimale inhibitrice (AUC24/MIC) en tant qu'indice pharmacodynamique, vraisemblablement pour prédire certains résultats concernant les patients présentant des infections associées au SAMR. OBJECTIFS: Déterminer le taux de discordance entre la concentration minimale et les valeurs de l'AUC24/MIC et la manière dont les échecs de traitement et les résultats de néphrotoxicité se comparent entre les personnes atteignant leurs cibles pharmacodynamiques et celles qui ne l'atteignent pas. MÉTHODES: Cette étude de cohorte rétrospective impliquait des patients atteints d'une bactériémie au SAMR ou d'une pneumonie au SAMR, admis à l'hôpital où se déroulait l'étude entre le 1er mars 2014 et le 31 décembre 2018 et traités à l'aide de vancomycine. Les données relatives aux concentrations minimales ont été recueillies, et les concentrations minimales (C min) extrapolées. Les valeurs de l'AUC24/MIC ont été déterminées à l'aide de modèles de population pharmacocinétiques validés. La caractérisation des valeurs de la C min et des valeurs de l'AUC24/MIC se décrit comme suit: « en dessous ¼, « à l'intérieur ¼ ou « au-dessus ¼ des cibles pharmacodynamiques (respectivement 15­20 mg/L et 400­600). La discordance était définie comme une situation où les valeurs associées de la C min et de l'AUC24/MIC tombaient dans des plages différentes (c.-à-d., en dessous, à l'intérieur ou au-dessus) par rapport aux plages cibles. Une régression logistique a permis de déterminer les prédicteurs d'échecs de traitement et de néphrotoxicité. RÉSULTATS: Au total, 128 patients ont été inclus dans les analyses. De ceux-ci, 73 (57 %) ont reçu une dose initiale de vancomycine de moins de 15 mg/kg. Le taux de discordance entre les valeurs de la C min et de l'AUC24/MIC était de 21 % (27/128). Les taux d'échec de traitement et de néphrotoxicité se montaient respectivement à 34 % (43/128) et 18 % (23/128). Aucune variable clinique n'a pu prédire la discordance. La régression logistique a permis de déterminer le début de l'administration de la vancomycine après un résultat de culture positif (rapport de cotes [RC] 4,41, 95 % intervalle de confiance [IC] 1,36­14,3) et l'atteinte de la cible de l'AUC24/MIC après quatre jours (RC 3,48, 95 % IC 1,39­8,70) en tant que prédicteurs modifiables de l'échec du traitement. CONCLUSIONS: Il existe probablement une confusion relative à la relation entre la surveillance de la vancomycine et le résultat à cause d'un dosage empirique ou initial inadéquat. Avant de modifier la pratique relative à la surveillance de la vancomycine, le pharmacien doit optimiser son dosage empirique.

Rational design and synthesis of substrate-product analogue inhibitors of α-methylacyl-coenzyme A racemase from Mycobacterium tuberculosis.

2,2-Bis(4-isobutylphenyl)propanoyl-CoA and 2,2-bis(4-t-butylphenyl)propanoyl-CoA are rationally designed, gem-disubstituted substrate-product analogues that competitively inhibit α-methylacyl-coenzyme A racemase from Mycobacterium tuberculosis with Ki values of 16.9 ± 0.6 and 21 ± 4 µM, respectively, exceeding the enzyme's affinity for the substrate by approximately 5-fold.

Binding kinetics and affinities of heterodimeric versus homodimeric HIV-1 reverse transcriptase on DNA-DNA substrates at the single-molecule level.

During viral replication, HIV-1 reverse transcriptase (RT) plays a pivotal role in converting genomic RNA into proviral DNA. While the biologically relevant form of RT is the p66-p51 heterodimer, two recombinant homodimer forms of RT, p66-p66 and p51-p51, are also catalytically active. Here we investigate the binding of the three RT isoforms to a fluorescently labeled 19/50-nucleotide primer/template DNA duplex by exploiting single-molecule protein-induced fluorescence enhancement (SM-PIFE). PIFE, which does not require labeling of the protein, allows us to directly visualize the binding/unbinding of RT to a double-stranded DNA substrate. We provide values for the association and dissociation rate constants of the RT homodimers p66-p66 and p51-p51 with a double-stranded DNA substrate and compare those to the values recorded for the RT heterodimer p66-p51. We also report values for the equilibrium dissociation constant for the three isoforms. Our data reveal great similarities in the intrinsic binding affinities of p66-p51 and p66-p66, with characteristic Kd values in the nanomolar range, much smaller (50-100-fold) than that of p51-p51. Our data also show discrepancies in the association/dissociation dynamics among the three dimeric RT isoforms. Our results further show that the apparent binding affinity of p51-p51 for its DNA substrate is to a great extent time-dependent when compared to that of p66-p66 and p66-p51, and is more likely determined by the dimer dissociation into its constituent monomers rather than the intrinsic binding affinity of dimeric RT.