Individualised antimicrobial dosing in critically ill patients undergoing continuous renal replacement therapy: focus on total drug clearance.

BACKGROUND: Continuous renal replacement therapy (CRRT) is common practice in critical care patients with acute renal failure. OBJECTIVES: To evaluate the adequacy of antimicrobial doses calculated based on the total drug clearance and dose recommended by different guides in critically ill patients undergoing CRRT. METHODS: Retrospective observational study. Patients admitted to a critical care unit during May 2014 to May 2016 and subjected to CRRT were included. The recommended dose was established as the product of the usual dose of the drug by total drug clearance. RESULTS: 177 antimicrobial agents, used in 64 patients were analysed; 45 (25.4%) antimicrobials were given in an insufficient dose (<20%) according to the theoretical calculation. Following the recommendations in the revised guidelines, between 10% and 20% of antimicrobials were given in insufficient doses. A higher success rate of treatment in those patients not receiving a low drug dosage was seen (35.2% vs 24.0%). CONCLUSIONS: There is a great disparity between the antimicrobial dose prescribed, recommended and calculated based on drug clearance in critically ill patients undergoing CRRT.

Septic Participation in Cardiogenic Shock: Exposure to Bacterial Endotoxin.

OBJECTIVE: In cardiogenic shock (CS), presence of fever, leukocytosis, relatively low systemic vascular resistances, and high serum procalcitonin levels are quite frequent and recurrently involve the search for an infectious complication. We hypothesized that endotoxin exposure in CS could explain this sepsis-like syndrome. DESIGN AND SETTING: Prospective observational study of consecutive CS patients admitted to our intensive care unit (ICU). Patients were followed during the first 3 days after CS onset. All clinical, hemodynamic, and microbiological data were collected. Inflammatory biomarkers and anti-endotoxin antibodies (IgM EndoCAb) were daily measured. PATIENTS: We included 37 consecutive CS patients. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients (60%) had body temperature >38.3°C or <35°C; and 23 patients (62%) had a leucocyte count >14,000/mm or <4,000/mm. Microbiological study was performed in 30 patients (81%). No infection was diagnosed in the studied patients. All the patients had serum inflammatory biomarkers levels above normal values including procalcitonin (19 patients [51%] had serum procalcitonin above 2 ng/mL). All the patients had IgM EndoCAb below the normal median value; 22 patients (59.5%) had IgM anti-endotoxin value below 10th percentile range for healthy people. Hemodynamic and respiratory stabilization was achieved in 23 patients (62%) and the ICU mortality rate was 38%, only procalcitonin and interleuquin-6 were associated with higher mortality rate. CONCLUSION: We have detected extremely low titers of IgM EndoCAb in CS suggesting endotoxin exposure. However, only inflammatory biomarkers were related to ICU mortality.