The strategy of antibiotic use in critically ill neutropenic patients

Legrand, Matthieu; Max, Adeline; Schlemmer, Benoît; Azoulay, Elie; Gachot, Bertrand

doi:10.1186/2110-5820-1-22

Annals of Intensive Care

Table 3 Suggested dosages for empirical antibiotic therapy in high-risk adult neutropenic patients with normal renal function

From: The strategy of antibiotic use in critically ill neutropenic patients

	Dosage	Targets for serum concentrations
Cefepime	2 g iv every 8-12 hours	Max. T > MIC (at least 70% of the dosing interval)
Piperacillin-tazobactam ^#	4 g/500 mg iv every 6-8 hours	Max. T > MIC (at least 70% of the dosing interval)
Ceftazidime ^#	1-2 g every 8 hours or 2 g loading dose followed by 6 g continuous iv infusion every 24 hours	Max. T > MIC (at least 70% of the dosing interval)
Imipenem ^#	500 mg every 6 hours to 1 g iv every 6-8 hours Up to 50 mg/kg/day for seriously ill patients: 1 g iv every 6-8 hours	Max. T > MIC (at least 70% of the dosing interval)
Meropenem ^#	0.5-1 g iv infusion every 8 hours for seriously ill patients: 1 g iv infusion every 8 hours	Max. T > MIC (at least 70% of the dosing interval)
Amikacin*	15-20 mg/kg once daily for seriously ill patients: 25-30 mg/kg once daily	Peak/MIC ratio > 8-10	Peak: 64-80 μg/ml Trough < 2.5 μg/ml
Gentamicin* tobramycin*	3-5 mg/kg iv once daily for seriously ill patients: 7-8 mg/kg iv once daily	Peak/MIC ratio > 8-10	Peak: 32-40 μg/ml Trough < 0.5 μg/ml
Vancomycin*	15-20 mg/kg ¤ given every 8-12 hours for seriously ill patients: loading dose of 25-30 mg/kg or loading dose of 15 mg/kg iv followed by 30-60 mg/kg continuous iv infusion every 24 hours	Optimal 24 h-AUC/MIC ratio > 400	Trough: > 15-20 mg/L, 25-35 mg/L if severe infection Always > 10 mg/L to avoid the development of resistance
Teicoplanin*	6-12 mg/kg every 12 hours iv from day 1 to 4 followed by 6-12 mg/kg every 24 hours	Optimal 24 h-AUC/MIC ratio > 400	Trough: 20-30 mg/L
Ciprofloxacin ^#	400 mg every 8-12 hours	Optimal 24 h-AUC/MIC ratio ~125 for Gram-negative bacteria Optimal 24 h-AUC/MIC ratio ~40 for Gram-positive bacteria
Colimycin	75,000-150,000 IU/kg (2.5-5 mg/kg colistin base) every 24 hours in 3 divided doses

The local bacterial ecology and patient's bacterial history must be considered when selecting empirical antibiotics.
^#Note that the highest suggested dosage is active against Pseudomonas aeruginosa.
*Routine determination of trough serum levels is required. For aminoglycosides, renal impairment may occur after a few days of treatment; therefore, treatment duration should be limited to 48-72 hours and should not exceed 5 days. Multiple daily doses of aminoglycosides are discouraged, because this regimen does not reduce toxicity and cannot provide sufficient peak serum concentrations; peak concentration should be determined 30 minutes after the end of the infusion and trough concentration just before the next infusion. For vancomycin, trough serum concentrations should be obtained just before the fourth dose. There is no evidence that continuous infusion regimens improve patient outcomes. The recommended infusion rate is 0.5-1 g/h. Monitoring of trough serum vancomycin concentrations is recommended for patients receiving aggressive dose targeting, for patients with unstable renal function, and for patients receiving concurrent treatment with nephrotoxic agents.
^¤Should be calculated based on actual body weight.
iv, intravenous.

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