Abstract
ObjectiveUnpredictable pharmacokinetics of antibiotics in patients with life-threatening bacterial infections is associated with drug under- or overdosing. Therapeutic drug monitoring (TDM) may guide dosing adjustment aimed at maximizing antibacterial efficacy and minimizing toxicity. Rapid and accurate analytical methods are key for real-time TDM. Our objective was to develop a robust high-performance liquid chromatography-tandem mass spectrometry method (HPLC-MS/MS) for multiplex quantification of plasma concentrations of 12 antibiotics: imipenem/cilastatin, meropenem, ertapenem, cefepime, ceftazidime, ceftriaxone, piperacillin/tazobactam, amoxicillin, flucloxacillin, rifampicin, daptomycin. MethodsA single extraction procedure consisting in methanol plasma protein precipitation and H2O dilution was used for all analytes. After chromatographic separation on an Acquity UPLC HSS-T3 2.1 × 50 mm, 1.8 µm (Waters®) column, quantification was performed by electro-spray ionisation-triple quadrupole mass spectrometry with selected reaction monitoring detection. Antibiotics were divided in two pools of calibration according to the frequency of analyses requests in the hospital routine antibiotic TDM program. Stable isotopically-labelled analogues were used as internal standards. A single analytical run lasted less than 9 min. ResultsThe method was validated based on FDA recommendations, including assessment of extraction yield (96–113.8%), matrix effects, and analytical recovery (86.3–99.6%). The method was sensitive (lower limits of quantification 0.02–0.5 µg/mL), accurate (intra/inter-assay bias −11.3 to +12.7%) and precise (intra/inter-assay CVs 2.1–11.5%) over the clinically relevant plasma concentration ranges (upper limits of quantification 20–160 µg/mL). The application of the TDM assay was illustrated with clinical cases that highlight the impact on patients’ management of an analytical assay providing information with short turn-around time on antibiotic plasma concentration. ConclusionThis simple, robust high-throughput multiplex HPLC-MS/MS assay for simultaneous quantification of plasma concentrations of 12 daily used antibiotics is optimally suited for clinically efficient real-time TDM.
Highlights
The development of new antimicrobial agents does not keep the pace with rising bacterial resistance
The application of the Therapeutic drug monitoring (TDM) assay was illustrated with clinical cases that highlight the impact on patients’ management of an analytical assay providing information with short turn-around time on antibiotic plasma concentration. This simple, robust high-throughput multiplex HPLC-mass spectrometry (MS)/MS assay for simultaneous quantification of plasma concentrations of 12 daily used antibiotics is optimally suited for clinically efficient real-time TDM
We found a 50% probability of toxic encephalopathy at trough cefepime plasma concentrations above 22 g/mL in febrile neutropenic patients with mild impairment of renal function[9]
Summary
The development of new antimicrobial agents does not keep the pace with rising bacterial resistance. Increase of antibiotic dosing following documentation of insufficient plasma concentrations, i.e. trough concentrations lower than the in vitro minimal inhibitory drug concentration (MIC) for the causative microbe, may improve response of life-threatening infections [2,3,4,5] and avoid selection of bacterial resistance. This scenario is frequently observed in ICU patients with augmented renal clearance (e.g. hyperfiltration)[6]. Quantification of antibiotic plasma concentrations may be perturbed by endogenous and exogenous compounds from very complex, highly variable plasma matrices influenced by renal
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