Lewis Susan J, Mueller Bruce A
Department of Clinical Social and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, Michigan.
Semin Dial. 2014 Sep-Oct;27(5):441-5. doi: 10.1111/sdi.12203.
Published CRRT drug dosing algorithms and other dosing guidelines appear to result in underdosed antibiotics, leading to failure to attain pharmacodynamic targets. High mortality rates persist with inadequate antibiotic therapy as the most important risk factor for death. Reasons for unintended antibiotic underdosing in patients receiving CRRT are many. Underdosing may result from lack of the recognition that better hepatic function in AKI patients yields higher nonrenal antibiotic clearance compared to ESRD patients. Other factors include the variability in body size and fluid composition of patients, the serious consequence of delayed achievement of antibiotic pharmacodynamic targets in septic patients, potential subtherapeutic antibiotic concentrations at the infection site, and the influence of RRT intensity on antibiotic concentrations. Too often, clinicians weigh the benefits of overcautious antibiotic dosing to avoid antibiotic toxicity too heavily against the benefits of rapid attainment of therapeutic antibiotic concentrations in critically ill patients receiving CRRT. We urge clinicians to prescribe antibiotics aggressively for these vulnerable patients.
已发表的连续性肾脏替代治疗（CRRT）药物给药算法及其他给药指南似乎会导致抗生素剂量不足，从而无法达到药效学目标。抗生素治疗不足作为死亡的最重要风险因素，高死亡率持续存在。接受CRRT的患者出现意外抗生素剂量不足的原因有很多。剂量不足可能是由于未认识到急性肾损伤（AKI）患者比终末期肾病（ESRD）患者具有更好的肝功能，从而产生更高的非肾脏抗生素清除率。其他因素包括患者体型和体液成分的变异性、脓毒症患者延迟达到抗生素药效学目标的严重后果、感染部位潜在的亚治疗性抗生素浓度以及肾脏替代治疗强度对抗生素浓度的影响。临床医生常常过于看重谨慎使用抗生素以避免抗生素毒性的益处，而相对忽视了在接受CRRT的重症患者中迅速达到治疗性抗生素浓度的益处。我们敦促临床医生为这些脆弱的患者积极开具抗生素处方。
