Barriers and Facilitators in the Clinical Implementation of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: A Critical Review

Abdulla, Alan; Broek, Puck van den; Ewoldt, Tim M J; Muller, Anouk E.; Endeman, Henrik; Koch, Birgit C. P.

doi:10.1097/ftd.0000000000000937

Cited by 16 publications

(16 citation statements)

References 32 publications

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“…Unfortunately, commercially assays are not yet available for beta-lactams as there are for aminoglycosides and glycopeptides and few hospitals can perform high-performance liquid chromatography or mass spectrometry essays ( 34 ). Others barriers to widespread incorporation of beta-lactam TDM into clinical practice are insufficient knowledge among health care providers, lack of cost-effectiveness evaluation and, as cited above, availability of bacterial susceptibility information ( 45 ).…”

Section: Discussionmentioning

confidence: 99%

Beta-Lactams Therapeutic Monitoring in Septic Children–What Target Are We Aiming for? A Scoping Review

et al. 2022

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The antimicrobial therapy of sepsis and septic shock should be individualized based on pharmacokinetic/pharmacodynamic (PK/PD) parameters to deliver effective and timely treatment of life-threatening infections. We conducted a literature scoping review to identify therapeutic targets of beta-lactam antibiotics in septic pediatric patients and the strategies that have been applied to overcome sepsis-related altered pharmacokinetics and increase target attainment against susceptible pathogens. A systematic search was conducted in the MEDLINE, EMBASE and Web of Science databases to select studies conducted since 2010 with therapeutic monitoring data of beta-lactams in septic children. Last searches were performed on 02 September 2021. Two independent authors selected the studies and extracted the data. A narrative and qualitative approach was used to summarize the findings. Out of the 118 identified articles, 21 met the eligibility criteria. Population pharmacokinetic modeling was performed in 12 studies, while nine studies reported data from bedside monitoring of beta-lactams. Most studies were conducted in the United States of America (n = 9) and France (n = 5) and reported PK/PD data of amoxicillin, ampicillin, azlocillin, aztreonam, cefazolin, cefepime, cefotaxime, ceftaroline, ceftazidime, doripenem, meropenem and piperacillin/tazobactam. Therapeutic targets ranged from to 40% fT> MIC to 100% fT> 6 × MIC. Prolonging the infusion time and frequency were most described strategies to increase target attainment. Monitoring beta-lactam serum concentrations in clinical practice may potentially maximize therapeutic target attainment. Further studies are required to define the therapeutic target associated with the best clinical outcomes.

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Section: Discussionmentioning

confidence: 99%

Beta-Lactams Therapeutic Monitoring in Septic Children–What Target Are We Aiming for? A Scoping Review

et al. 2022

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“…Still, it has to be clarified which group of patients might benefit the most from TDM. This is especially important because, in times of high financial and workforce pressures, costs and benefits of diagnostics must be carefully weighed against each other before widespread implementation of β-lactam TDM programs are recommended [ 47 ].…”

Section: Discussionmentioning

confidence: 99%

Early Target Attainment With Continuous Infusion Meropenem and Piperacillin/Tazobactam and Utilization of Therapeutic Drug Monitoring in Critically Ill Patients: A Retrospective Cohort Study From 2017 to 2020

Dräger

Rotz

Labhardt

et al. 2023

Open Forum Infectious Diseases

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Objectives We analyzed the attainment of early pharmacological targets of continuous infusion meropenem and piperacillin/tazobactam and the use and effect of a real-time TDM program on subsequent dosing and target attainment in critically ill patients. Methods This was a single centre, retrospective study among patients hospitalized in the intensive care unit in a Swiss tertiary care hospital from 2017 to 2020. The primary outcome was target attainment [100% tT≥4xECOFF (Pseudomonas aeruginosa)] of continuous infusion meropenem and piperacillin/tazobactam within 72h after initiation of treatment. Results A total of 234 patients were included. Median first meropenem (n=186/234) and piperacillin (n=48/234) concentration was 21 mg/L (IQR 15.6-28.6) and 100.7 mg/L (IQR 64.0-160.2), respectively. Pharmacological target was attained in 95.7% (95% confidence interval 91.7-98.1) of patients receiving meropenem and 77.0% (95%CI 62.7-87.9) treated with piperacillin/tazobactam. In the univariable and multivariable logistic regression, body weight and estimated glomerular filtration rate were negatively associated with target attainment. Subsequently, meropenem dosage was decreased or stopped in 35/186 (18.8%) and 89/186 (47.9%) patients, respectively and increased in 2/186 (1.1%) patients. Conclusions Continuous infusion meropenem and piperacillin/tazobactam yielded excellent and moderate early pharmacological target attainment in critically ill patients, respectively. TDM was mainly used to decrease meropenem dosage.

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“…In the current study, we also found that ciprofloxacin TDM was less often applied and more obscure than beta-lactams TDM. Abdulla et al reviewed current barriers and facilitators for the clinical implementation of beta-lactams TDM in critically ill patients [ 23 ]. They noted that important barriers were the limited availability of assays and a lack of guidelines, which is also reflected in our results.…”

Section: Discussionmentioning

confidence: 99%

“…However, the translation into clinical implementation is only sparingly reported [ 1 , 20 – 22 ]. A recent review suggested that several barriers need to be overcome, such as assay availability, clinical evidence, and proof of cost-effectiveness, to facilitate the optimal implementation of beta-lactams TDM in critically ill patients [ 23 ]. However, no study included in this review used a systematic method to identify barriers and facilitators.…”

Section: Introductionmentioning

confidence: 99%

Barriers and facilitators for therapeutic drug monitoring of beta-lactams and ciprofloxacin in the ICU: a nationwide cross-sectional study

et al. 2022

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Background Recent studies demonstrated that failure of achieving pharmacodynamic targets of commonly used antibiotics is common in critically ill patients. Therapeutic drug monitoring (TDM) can contribute to optimize the exposure of beta-lactams and ciprofloxacin. While evidence for TDM of these antibiotics is growing, translation into clinical implementation remains limited. Therefore, perceived barriers and facilitators are important for implementing TDM in this population. The primary aim of this study was to identify healthcare professionals’ barriers and facilitators for the implementation of TDM of beta-lactams and ciprofloxacin in Dutch intensive care units (ICU). Methods We conducted a nationwide cross-sectional online survey among healthcare professionals (HCPs) involved in antibiotic treatment of ICU patients. An adapted version of the Measurement Instrument for Determinants of Innovations was sent out. Items were considered barriers when ≥ 20% of participants responded with a negative answer. If ≥ 80% of the participants responded with a positive answer, the item was considered a facilitator. Results Sixty-four HCPs completed the survey, of which 14 were from academic hospitals, 25 from general hospitals, and 25 from teaching hospitals. Most participants were hospital pharmacists (59%) or medical specialists (23%). Eleven barriers and four facilitators for implementation of TDM of beta-lactams were identified; 17 barriers for TDM of ciprofloxacin and no facilitators. The most important barriers were a lack of conclusive evidence, organizational support, and low availability of assays. Additional barriers were a lack of consensus on which specific patients to apply TDM and which pharmacodynamic targets to use. Identified facilitators for beta-lactam TDM implementation are low complexity and high task perception, combined with the perception that TDM is important to prevent side effects and to adequately treat infections. Twenty-eight percent of participants reported that flucloxacillin could be analyzed in their hospital. Assay availability of other beta-lactams and ciprofloxacin was lower (3–17%). Conclusion Several barriers were identified that could obstruct the implementation of TDM of beta-lactams and ciprofloxacin in the ICU. In particular, education, clear guidelines, and organizational support should be considered when creating tailored implementation strategies. Finally, evidence of beneficial clinical outcomes on TDM of beta-lactams and ciprofloxacin can enhance further implementation.

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Barriers and Facilitators in the Clinical Implementation of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients: A Critical Review

Cited by 16 publications

References 32 publications

Beta-Lactams Therapeutic Monitoring in Septic Children–What Target Are We Aiming for? A Scoping Review

Beta-Lactams Therapeutic Monitoring in Septic Children–What Target Are We Aiming for? A Scoping Review

Early Target Attainment With Continuous Infusion Meropenem and Piperacillin/Tazobactam and Utilization of Therapeutic Drug Monitoring in Critically Ill Patients: A Retrospective Cohort Study From 2017 to 2020

Barriers and facilitators for therapeutic drug monitoring of beta-lactams and ciprofloxacin in the ICU: a nationwide cross-sectional study

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