O papel da monitorização das concentrações de vancomicina e amicacina no plasma e no dialisato de pacientes com peritonite associada à diálise peritoneal
Carregando...
Data
2020-02-21
Autores
Reis, Pâmela Falbo
Título da Revista
ISSN da Revista
Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
Introdução: Peritonite é complicação grave nos pacientes em diálise peritoneal (DP) e a principal causa de transição para hemodiálise. O uso intraperitoneal (IP) de aminoglicosídeo e vancomicina é opção para o tratamento empírico. No entanto, a absorção sistêmica dessas drogas é controversa e pouco estudada. Objetivo: Descrever os níveis plasmáticos e do dialisato de amicacina e vancomicina administrados IP em pacientes com peritonite em DP nos momentos de 30 e 120 min após administração, após 24h da administração da amicacina e 48h da vancomicina e associá-los com o desfecho da peritonite. Metodologia: Estudo observacional realizado de novembro/2017 a abril/2019, que incluiu 32 episódios de peritonites. Análise de amostras foi realizada no 1º, 3º e 5º dias. No momento de pico, foram consideradas concentrações terapêuticas de amicacina valores entre 25 e 35 mg/L e no vale (antes da infusão do dialisato) concentrações de 4-8 mg/L ; e de vancomicina no vale de 15–20 mg/L. Resultados: A idade foi de 60 ± 11,3 anos, a principal causa da doença renal foi diabetes (42,4%) e 63,3% eram homens. Entre as culturas 39,4% foram gram negativos, 36,3% gram positivos e 21,2% negativas. Houve cura em 84,8% dos episódios. Vancomicina foi administrada IP a cada 72h e amicacina diariamente. Avaliando-se os períodos antes e depois da peritonite, não houve mudanças no tipo de transporte peritoneal (p=0,76), mas houve diferenças na função renal residual (p=0,05) e redução do débito urinário (p=0,02). Quanto aos desfechos cura e não cura, não houve diferença quanto ao gênero, idade, celularidade no 1º dia ou diabetes. A celularidade no 3º dia foi menor no grupo cura (p=0,009). No momento de pico, níveis terapêuticos de amicacina foram atingidos no dialisato em 80,7% dos pacientes com evolução para cura e 50% dos pacientes que evoluíram com não cura (p=0,05). No momento de vale, apenas 38% encontravam-se em concentrações terapêuticas no dialisato no grupo cura e 42,8% no não cura (p=1). As concentrações plasmáticas no momento de pico foram subterapêuticos em 98,4% das amostras no grupo cura e 100% no não cura. Já no momento de vale, concentrações plasmáticas terapêuticas estavam presentes em 74,4% no grupo cura e 71,4% no não cura (p=1). Quanto à vancomicina, foram atingidos níveis terapêuticos no pico em 94% dos curados e em 6% no grupo não cura (p=0,007). Após 48h, 56,8% do grupo cura teve concentração terapêutica no plasma, enquanto no grupo não cura foram 33,3% (p=0,39). As concentrações após 48h foram terapêuticas no dialisato em 5,4% no grupo cura e não foram atingidos no grupo não cura (p=1). Conclusão: A avaliação das concentrações de amicacina e vancomicina no dialisato e plasma mostram que, no momento de pico, concentrações terapêuticas de amicacina são necessários no dialisato para o sucesso terapêutico, enquanto as concentrações de vancomicina no plasma parecem ser mais importantes para o desfecho cura. Portanto, é importante estudar a farmacocinética dessas drogas para melhor compreensão do sucesso terapêutico.
Introduction: Peritonitis is a serious complication in patients on peritoneal dialysis and the main cause of transition to hemodialysis. The intraperitoneal use of aminoglycoside and vancomycin is an option for empiric treatment. However, the systemic absorption of these drugs is controversial and little studied. Objectives: Describe intraperitoneal amikacin and vancomycin dialysate levels in patients with peritonitis on peritoneal dialysis at 30 and 120 minutes after administration, 48 hours after vancomycin and 24 hours after amikacin and associating them with the peritonitis outcome. Methodology: Observational study conducted from August 2017 to April 2019, which included 32 episodes of peritonitis. Samples were analyzed on the 1st, 3rd and 5th days. At peak moment, therapeutic concentrations of amikacin were considered to be between 25 and 35 mg/L and at baseline concentrations of 4-8 mg/L; and vancomycin at the valley moment of 15-20 mg/L. Results: Age was 60 ± 11.3 years, the main cause of kidney disease was diabetes (42.4%) and 63.3% were men. Among the cultures 39.4% were gram negative, 36.3% gram positive and 21.2% negative. There was cure in 84.8% of the episodes. Vancomycin was administered intraperitoneal every 72 hours and amikacin daily. There were no changes in the peritoneal transport type (p = 0.76), but there were differences in residual renal function (p = 0.05) and reduction in urinary output (p = 0.02). Regarding the outcomes of cure and non-cure, there was no difference regarding gender, age, cellularity in the 1st day or diabetes. The cellularity on day 3 was lower in the cure 17 group (p = 0.009). At the time of peak, therapeutic levels of amikacin were reached in dialysate in 80.7% of patients with evolution to cure and 50% of patients who evolved with non-cure (p = 0.05). At the time of valley, only 38% were in therapeutic concentrations in the dialysate in the cure group and 42.8% in the non-cure (p = 1). Peak plasma concentrations were subtherapeutic in 98.4% of the samples in the cure group and 100% in the non-cure. At the time of valley, therapeutic concentrations were present in 74.4% in the cure group and 71.4% in the non-cure (p = 1). Regarding vancomycin, therapeutic levels were reached at peak in 94% of the cured and in 6% in the non-cure group (p = 0.007). After 48 hours, 56.8% of the cure group had a therapeutic concentration in the plasma, while in the non-cure group there were 33.3% (p = 0.39). The concentrations after 48 hours were therapeutic in the dialysate in 5.4% in the cure group and were not reached in the non-cure group (p = 1). Conclusions: The assessment of amikacin and vancomycin concentrations in dialysate and plasma illustrates that, at peak time, therapeutic concentrations of amikacin are required in the dialysate for therapeutic success, whereas plasma vancomycin concentrations appear to be more important for the cure outcome. Therefore, it is important to study the pharmacokinetics of these drugs for a better understanding of therapeutic success.
Introduction: Peritonitis is a serious complication in patients on peritoneal dialysis and the main cause of transition to hemodialysis. The intraperitoneal use of aminoglycoside and vancomycin is an option for empiric treatment. However, the systemic absorption of these drugs is controversial and little studied. Objectives: Describe intraperitoneal amikacin and vancomycin dialysate levels in patients with peritonitis on peritoneal dialysis at 30 and 120 minutes after administration, 48 hours after vancomycin and 24 hours after amikacin and associating them with the peritonitis outcome. Methodology: Observational study conducted from August 2017 to April 2019, which included 32 episodes of peritonitis. Samples were analyzed on the 1st, 3rd and 5th days. At peak moment, therapeutic concentrations of amikacin were considered to be between 25 and 35 mg/L and at baseline concentrations of 4-8 mg/L; and vancomycin at the valley moment of 15-20 mg/L. Results: Age was 60 ± 11.3 years, the main cause of kidney disease was diabetes (42.4%) and 63.3% were men. Among the cultures 39.4% were gram negative, 36.3% gram positive and 21.2% negative. There was cure in 84.8% of the episodes. Vancomycin was administered intraperitoneal every 72 hours and amikacin daily. There were no changes in the peritoneal transport type (p = 0.76), but there were differences in residual renal function (p = 0.05) and reduction in urinary output (p = 0.02). Regarding the outcomes of cure and non-cure, there was no difference regarding gender, age, cellularity in the 1st day or diabetes. The cellularity on day 3 was lower in the cure 17 group (p = 0.009). At the time of peak, therapeutic levels of amikacin were reached in dialysate in 80.7% of patients with evolution to cure and 50% of patients who evolved with non-cure (p = 0.05). At the time of valley, only 38% were in therapeutic concentrations in the dialysate in the cure group and 42.8% in the non-cure (p = 1). Peak plasma concentrations were subtherapeutic in 98.4% of the samples in the cure group and 100% in the non-cure. At the time of valley, therapeutic concentrations were present in 74.4% in the cure group and 71.4% in the non-cure (p = 1). Regarding vancomycin, therapeutic levels were reached at peak in 94% of the cured and in 6% in the non-cure group (p = 0.007). After 48 hours, 56.8% of the cure group had a therapeutic concentration in the plasma, while in the non-cure group there were 33.3% (p = 0.39). The concentrations after 48 hours were therapeutic in the dialysate in 5.4% in the cure group and were not reached in the non-cure group (p = 1). Conclusions: The assessment of amikacin and vancomycin concentrations in dialysate and plasma illustrates that, at peak time, therapeutic concentrations of amikacin are required in the dialysate for therapeutic success, whereas plasma vancomycin concentrations appear to be more important for the cure outcome. Therefore, it is important to study the pharmacokinetics of these drugs for a better understanding of therapeutic success.
Descrição
Palavras-chave
Diálise, Peritonite, Amicacina, Vancomicina, Farmacocinética, Dialysis, Peritonitis, Amikacin, Vancomycin, Pharmacokinetics