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Impact of hospital guideline for weight‐based antimicrobial dosing in morbidly obese adults and comprehensive literature review
Author(s) -
Polso A. K.,
Lassiter J. L.,
Nagel J. L.
Publication year - 2014
Publication title -
journal of clinical pharmacy and therapeutics
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.622
H-Index - 73
eISSN - 1365-2710
pISSN - 0269-4727
DOI - 10.1111/jcpt.12200
Subject(s) - dosing , morbidly obese , guideline , medicine , antimicrobial , intensive care medicine , obesity , weight loss , microbiology and biotechnology , biology , pathology
Summary What is known and objective Obesity is a significant burden on the healthcare system in the U nited S tates, and determining the appropriate antimicrobial dosing regimen in morbidly obese patients is challenging. Morbidly obese patients have documented differences in pharmacokinetic and pharmacodynamic properties compared to normal‐weight patients, which impact antibiotic efficacy and toxicity. The F ood and D rug A dministration does not recognize obesity as a special population and does not require pharmaceutical companies to perform studies specific to obese patients. However, there are an increasing number of post‐approval studies in obese patients, and this manuscript reviews available clinical and pharmacokinetic literature regarding weight‐based antimicrobial agents. Additionally, we describe a single‐centre approach to optimize dosing in morbidly obese patients. Methods A comprehensive literature search was performed on 15 weight‐based antimicrobials in the setting of obesity: acyclovir, aminoglycosides, amphotericin B , cidofovir, colistimethate, daptomycin, flucytosine, foscarnet, ganciclovir, quinupristin/dalfopristin, trimethoprim/sulfamethoxazole, vancomycin and voriconazole. A weight‐based antimicrobial dosing guideline for morbidly obese patients was developed. An analysis of guideline compliance and cost analysis were performed following guideline implementation. Results and discussion This review describes the pharmacokinetic changes that occur in obese patients, including increased volume of distribution, altered hepatic metabolism, renal excretion and changes in protein binding. The majority of weight‐based antimicrobials result in increased serum concentrations in morbidly obese patients compared to normal‐weight patients when the calculated dose is based on actual body weight. What is new and conclusion This review demonstrates different antibiotic pharmacokinetic properties are altered in obese patients that could impact efficacy and toxicity. A single‐centre guideline for weight‐based antimicrobial dosing in obesity was developed and provides recommendations for using ideal body weight, adjusted body weight or actual body weight when calculating antimicrobial doses. However, more research is needed to better elucidate optimal dosing of weight‐based antimicrobials in obesity, with particular focus on efficacy and toxicity.