Résumé
Pathophysiological changes in critically ill patients can cause severely altered pharmacokinetics and widely varying antibiotic exposures. The impact of altered pharmacokinetics on bacterial killing and resistance has not been characterized in the dynamic hollow-fibre in vitro infection model (HFIM).
A clinical Pseudomonas aeruginosa isolate (piperacillin MIC 4 mg/L) was studied in the HFIM (inoculum similar to 10(7) cfu/mL). Pharmacokinetic profiles of three piperacillin dosing regimens (4 g 8-, 6- and 4-hourly, 30 min intravenous infusion) as observed in critically ill patients with augmented renal clearance (ARC), normal renal function or impaired renal function (creatinine clearances of 250, 110 or 30 mL/min, respectively) were simulated over 7 days. The time courses of total and less-susceptible populations and MICs were determined. Mechanism-based modelling was performed in S-ADAPT.
For all regimens with ARC and regimens with 8- or 6-hourly dosing with normal renal function, initial killing of >=similar to 2 log(10) was followed by regrowth to 10(8)-10(9) cfu/mL at 48 h. For 8- and 6-hourly dosing at normal renal function, the proportion of less-susceptible colonies increased similar to 10-100-fold above those in ARC and control arms. Regimens achieving an fC(min) of >= 5x MIC resulted in bacterial killing of 3-4 log(10) without regrowth and suppressed less-susceptible populations to >=similar to 2 log(10). The mechanism-based model successfully quantified the time course of bacterial growth, killing and regrowth.
Only high piperacillin concentrations prevented regrowth of P. aeruginosa. Individualized dosing regimens that account for altered pharmacokinetics and aim for higher-than-standard antibiotic exposures to achieve an fC(min) of >= 5x MIC were required to maximize bacterial killing and suppress emergence of resistance.