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aminoglycosides and vancomycin, as these antibiotics were
most appropriate for the causative pathogens observed in
ventilator associated pneumonia. Agents such as polymyxin
B and tigecycline are, fortunately, rarely required at our
hospital due to few CRAB and CRE organisms. However, should
this be different at another hospital, dosage selection and
implementation should follow the same strategy as described
above, which would include first, an understanding of MIC
distributions for your population, followed by implementation
of the most optimal dosing regimen to cover most of these
pathogens. A follow up evaluation after a defined period of
time (or number of cases treated) is paramount to ensuring
compliance and outcomes are in line with expectations. A
critical but common mistake, however, would be to simply
implement an optimized dosing regimen that has been
described in the literature or used at another hospital without
consideration of your local epidemiology, as outcomes may be
largely different.
BIBLIOGRAPHIC REFERENCES
1. Boucher HW, Talbot GH, Bradley JS, et al. Bad bugs, no drugs:
no ESKAPE! An update from the Infectious Diseases Society of
America. Clin Infect Dis 2009;48:1-12.
2. Jones RN, Guzman-Blanco M, Gales AC, et al. Susceptibility
rates in Latin American nations: report from a regional
resistance surveillance program (2011). Braz J Infect Dis
2013;17:672-81.
3. US Department of Health and Human Services. Center for
Disease Control and Prevention. Antibiotic Resistance Threats
in the United States, 2013. Accessed at: .
gov/drugresistance/pdf/ar-threats-2013-508.pdf on July 1,
2016.
4. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an
antibiotic stewardship program: guidelines by the Infectious
Diseases Society of America and the Society of Healthcare
Epidemiology of America. Clin Infect Dis 2016;62:1-27.
5. Craig WA. Pharmacokinetic/pharmacodynamic parameters:
rationale for antibacterial dosing of mice and men. Clin Infect
Dis 1998;26:1-10.
6. Moore RD, Lietman PS, Smith CR, Clinical response to
aminoglycoside therapy: importance of the ratio of peak
concentration to minimal inhibitory concentration. J Infect
Dis 1987;155:93-9.
7. Drusano GL, Ambrose PG, Bhavnani SM, Bertino JS, Nafziger AN,
Louie A. Back to the future: using aminoglycosides again and
how to dose them optimally. Clin Infect Dis 2007;45:753-60.
The author declares no conflicts of interest in relation to this article.
8. Nicolau DP, Freeman CD, Belliveau PP, Nightingale CH, Ross
JW, Quintiliani R. Experience with a once-daily aminoglycoside
program administered to 2,184 adult patients. Antimicrob
Agents Chemother 1995;39:650-5.
9. Drusano GL, Louie A. Optimization of aminoglycoside therapy.
Antimicrob Agents Chemother 2011;55:2528-31.
10. Chuck SK, Raber SR, Rodvold KA, Areff D. National survey of
extended-interval aminoglycoside dosing. Clin Infect Dis
2000;30:433-9.
11. Turnidge J. The pharmacodynamics of beta-lactams. Clin
Infect Dis 1998;27:10-22.
12. Crandon JL, Bulik CC, Kuti JL, Nicolau DP. Clinical
pharmacodynamics of cefepime in patients infected with
Pseudomonas aeruginosa. Antimicrob Agents Chemother
2010;54:1111-6.
13. MacVane SH, Kuti JL, Nicolau DP. Clinical pharmacodynamics
of antipsuedomonal cephalosporins in patients with ventilator
associated pneumonia. Antimicrob Agents Chemother
2014;58:1359-64.
14. Ong CT, Tessier PR, Li C, Nightingale CH, Nicolau DP.
Comparative in vivo efficacy of meropenem, imipenem,
and cefepime against Pseudomonas aeruginosa expressing
MexA-MexB-OprM efflux pumps. Diagn Microbiol Infect Dis
2007;57:153-61.
15. MacVane SH, Kuti JL, Nicolau DP. Prolonging beta-lactam
infusion: a review of the rationale and evidence, and guidance
SUMMARY
The continued rise of MDR bacteria in the hospital
setting has fostered the need for ASP and the use of
pharmacodynamically optimized dosing regimens to ensure
aggressive treatment of these infections. Optimized dosing
regimens for beta-lactams include higher doses combined
with continuous or prolonged infusions to increase the
fT>MIC. In contrast, aminoglycosides required the use of
higher doses and extended intervals. Finally, tigecycline and
polymyxin B regimens also required higher doses combined
with similar dosing intervals to increase the likelihood
of attaining pharmacodynamic exposure. The successful
implementation of one of these regimens, however, requires
a thorough understanding of local epidemiology and MIC
before any regimen can be selected.
[OPTIMIZING ANTIMICROBIAL PHARMACODYNAMICS: A GUIDE FOR YOUR STEWARDSHIP PROGRAM - Joseph L. Kuti, PharmD]