Christina Rose, BCCCP, PharmD, FCCM
Clinical Professor in Pharmacy Practice
Temple University School of Pharmacy
Haddonfield, NJ
Disclosure information not submitted.
Michelle Miller, PharmD
Pharmacist
Temple University School of Pharmacy
Philadephia, Pennsylvania, United States
Disclosure information not submitted.
Kazumi Morita, PharmD, BCPS
Pharmacist
Temple University Hospital, United States
Disclosure information not submitted.
Sheriff Gbadamosi, PharmD, BCCCP
Pharmacist
Temple University Hospital
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Kerry Mohrien, PharmD, BCPS
Clinical Pharmacy Specialist in Critical Care
Temple Uinversity Hospital
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Title: A therapeutic drug monitoring protocol in critically ill patients on extracorporeal organ support
Introduction: Therapeutic drug monitoring (TDM) of antimicrobials has the potential to optimize efficacy and minimize toxicity in a critically ill population. It has been shown that 50% of critically ill patients are unable to achieve goal beta-lactam serum concentrations. ICU patients receiving extracorporeal organ support may have unpredictable pharmacokinetics and may be an ideal population for TDM to optimize antimicrobial therapy.
Methods: A TDM pilot protocol in ICU patients was implemented at Temple University Hospital starting November 2020. Patients admitted to the ICU for greater than 24 hours and receiving an eligible antibiotic were evaluated for TDM. Patients receiving CRRT or ECMO are a subgroup of characteristics that qualify for TDM under the protocol. Goal therapeutic ranges for antimicrobials were based on published pharmacodynamic targets.
Results: A subset of patients receiving extracorporeal organ support were evaluated. A total of 37 initial samples were drawn from 30 patients receiving CRRT (17/37), ECMO (12/37) or a combination (COMB) of both (8/37). Cefepime, meropenem and piperacillin were the most common antimicrobials monitored. Of the 25 patients receiving CRRT, 24% received CVVHD and 76%, CVVHDF. 76% of patients received antimicrobial treatment for a definitive infection. Therapeutic values occurred in 25% (3/12), 35% (6/17) and 75% (6/8) of initial samples in patients receiving ECMO, CRRT or COMB, respectively. Subtherapeutic values were found in 75% (9/12) of initial samples in those receiving ECMO and in zero patients receiving CRRT or COMB. Supratherapeutic values were found in 0% (0/12), 65% (11/17) and 25% (2/8) of initial samples in patients receiving ECMO, CRRT or COMB, respectively. Modifications based on TDM occurred in 13/37 (35%). Modified regimens included a change in dose, frequency of administration, or a change in antimicrobial regimen.
Conclusions: Over 50% of patients on extracorporeal organ support were found to have drug concentrations out of the goal range. Subtherapeutic concentrations were commonly found in patients receiving ECMO while supratherapeutic concentrations were more common in CRRT. Antimicrobial TDM should be considered in critically patients on extracorporeal organ support.