Extensive Therapeutic Drug Monitoring of Colistin in Critically Ill Patients Reveals Undetected Risks

• Main Authors: Stefan Felix Ehrentraut, Stefan Muenster, Stefan Kreyer, Nils Ulrich Theuerkauf, Christian Bode, Folkert Steinhagen, Heidi Ehrentraut, Jens-Christian Schewe, Matthias Weber, Christian Putensen, Thomas Muders
• Format: Article
• Language: English
• Published: MDPI AG 2020-03-01
• Series: Microorganisms
• Subjects: colistin; sepsis; colistin methanosulfate; therapeutic drug monitoring; intensive care medicine; renal failure; polymyxin e; acinetobacter baumannii; carbapenem resistant
• Online Access: https://www.mdpi.com/2076-2607/8/3/415

(1) Background: With the rise of multi-/pan-drug resistant (MDR/PDR) pathogens, the less utilized antibiotic Colistin has made a comeback. Colistin fell out of favor due to its small therapeutic range and high potential for toxicity. Today, it is used again as a last resort substance in treating MDR/PDR pathogens. Although new guidelines with detailed recommendations for Colistin dosing are available, finding the right dose in critically ill patients with renal failure remains difficult. Here, we evaluate the efficiency of the current guidelines’ recommendations by using high resolution therapeutic drug monitoring of Colistin. (2) Methods: We analyzed plasma levels of Colistin and its prodrug colisthimethate sodium (CMS) in 779 samples, drawn from eight PDR-infected ICU patients, using a HPLC-MS/MS approach. The impact of renal function on proper Colistin target levels was assessed. (3) Results: CMS levels did not correlate with Colistin levels. Over-/Underdosing occurred regardless of renal function and mode of renal replacement therapy. Colistin elimination half-time appeared to be longer than previously reported. (4) Conclusion: Following dose recommendations from the most current guidelines does not necessarily lead to adequate Colistin plasma levels. Use of Colistin without therapeutic drug monitoring might be unsafe and guideline adherence does not warrant efficient target levels in critically ill patients.