Chiara Koch

Background: Acute-on-chronic liver failure (ACLF) is a severe, rapidly progressing syndrome in patients with liver cirrhosis, often triggered by bacterial infections. Piperacillin/Tazobactam is a key antibiotic in this setting, and therapeutic drug monitoring (TDM) helps optimize its dosing. This study evaluates the impact of an interprofessional TDM strategy for Piperacillin/Tazobactam in ACLF patients in the ICU. Methods: This retrospective ICU study evaluated an interprofessional TDM approach for optimizing Piperacillin/Tazobactam dosing in critically ill ACLF patients. The team, consisting of physicians, clinical pharmacists, and staff nurses, engaged in shared decision making, collaboratively interpreting TDM results and adjusting the dosing accordingly. This study included 26 patients with ACLF who underwent initial TDM and 7 who received follow-up TDM. Piperacillin/Tazobactam dosing was modified based on TDM recommendations, with serum concentrations measured weekly. Adherence to and the implementation of interprofessional dosing recommendations were systematically analyzed to assess the impact of this approach. Results: The initial TDM showed that 30.8% of patients had Piperacillin/Tazobactam levels within the target range, while 53.8% were above and 15.4% below. The interprofessional team recommended dose reductions in seven patients, increases in three, and no change in eleven, with five requiring antibiotic modifications. At the first follow-up TDM, 20.0% reached target levels, while 80.0% remained above, with no subtherapeutic cases. The team recommended one further dose reduction and maintained dosing in four patients. All recommendations were fully implemented, demonstrating strong adherence to the collaborative protocol. Conclusions: The interprofessional TDM strategy optimized Piperacillin/Tazobactam dosing in ACLF patients with full adherence to the recommendations. This collaborative approach improves outcomes and supports global efforts to curb antibiotic resistance.

Background: Critically ill patients requiring extracorporeal membrane oxygenation (ECMO) have several risk factors to suffer from abdominal compartment syndrome (ACS). Little is known about this subgroup. The aim of this study was to investigate the prevalence and associated factors for ACS in patients requiring ECMO to assess the effect of decompressive laparotomy (DL) and the impact on mortality. Methods: This retrospective observational study analyzed adult patients requiring ECMO in four intensive care units at the University Medical Center Regensburg between 01/2010 and 06/2020. Patients with clinically suspected ACS were screened by measuring intra-abdominal pressure (IAP) with the trans-bladder technique. ACS was defined as IAP > 20 mmHg and survival was defined as successful discharge from hospital. Results: The prevalence of ACS in non-ECMO ICU patients was 0.8% (291/36,795) and 2.9% (47/1643) in ECMO patients. In the subgroup of resuscitated ECMO patients, ACS was present in 4.2% (32/766). Procalcitonin was associated with ACS. ECMO patients with ACS receiving DL were significantly more ill compared to those without DL (SOFA score at ICU admission 18 [15; 20], vs. 16 [13; 17], p = 0.048). DL decreased IAP and significantly improved ventilation; vasopressor and lactate stabilized within 24 hours. Survival was comparable between the DL and the non-DL groups (11% [1/9] vs. 14% [1/7], p = 1.000). Conclusions: ECMO patients are at high risk of developing ACS, even more so for resuscitated patients. This and high procalcitonin may be taken into consideration when screening for ACS. Decompressive laparotomy did improve respiratory compliance and stabilized hemodynamic parameters with low rates of complication. Even though patients that received DL were significantly more ill, the mortality rates were not higher.

(1) Background: Acute-on-chronic liver failure (ACLF) is a severe, rapidly progressing disease in patients with liver cirrhosis. Meropenem is crucial for treating severe infections. Therapeutic drug monitoring (TDM) offers an effective means to control drug dosages, especially vital for bactericidal antibiotics like meropenem. We aimed to assess the outcomes of implementing TDM for meropenem using an innovative interprofessional approach in ACLF patients on a medical intensive care unit (ICU). (2) Methods: The retrospective study was conducted on a medical ICU. The outcomes of an interprofessional approach comprising physicians, hospital pharmacists, and staff nurses to TDM for meropenem in critically ill patients with ACLF were examined in 25 patients. Meropenem was administered continuously via an infusion pump after the application of an initial loading dose. TDM was performed weekly using high-performance liquid chromatography (HPLC). Meropenem serum levels, implementation of the recommendations of the interprofessional team, and meropenem consumption were analyzed. (3) Results: Initial TDM for meropenem showed a mean meropenem serum concentration of 20.9 ± 9.6 mg/L in the 25 analyzed patients. Of note, in the initial TDM, only 16.0% of the patients had meropenem serum concentrations within the respective target range, while 84.0% exceeded this range. Follow-up TDM showed serum concentrations of 15.2 ± 5.7 mg/L (9.0–24.6) in Week 2 and 11.9 ± 2.3 mg/L (10.2–13.5) in Week 3. In Week 2, 41.7% of the patients had meropenem serum concentrations that were within the respective target range, while 58.3% of the patients were above this range. In Week 3, 50% of the analyzed serum concentrations of meropenem were within the targeted range, and 50% were above the range. In total, 100% of the advice given by the interprofessional team regarding meropenem dosing or a change in antibiotic therapy was implemented. During the intervention period, the meropenem application density was 37.9 recommended daily doses (RDD)/100 patient days (PD), compared to 42.1 RDD/100 PD in the control period, representing a 10.0% decrease. (4) Conclusions: Our interprofessional approach to TDM significantly reduced meropenem dosing, with all the team’s recommendations being implemented. This method not only improved patient safety but also considerably decreased the application density of meropenem.