Hemoadsorption with CytoSorb® and the early course of linezolid plasma concentration during septic shock

Abstract

Hemoadsorption with CytoSorb® becomes increasingly established in treatment of various, predominantly inflammation-associated diseases. In septic shock, results suggest improvements in hemodynamics and organ function. However, little is known about the in vivo adsorption properties for various antibiotics. We present the case of a 61-year-old female patient with known Ulrich Turner syndrome who treated supportively with CytoSorb® and with linezolid due to a Staphylococcus epidermidis bloodstream infection as part of her intensive care treatment for septic shock. After establishment of a new adsorber, 600 mg of linezolid administered over 1 h. Linezolid levels measured before adsorber inlet (cpre) and after adsorber outlet (cpost) at 0, 15, 60, 120 and 480 min after starting infusion. Out of the ten samples, only the cpre samples 60 min (3.25 mg/l) and 120 min (4.7 mg/l) showed sufficiently high linezolid levels (therapeutic range 3–9 mg/l). After 480 min, cpre decreased to 2.8 mg/l, cpost increased to 1.85 mg/l, and thus clearance decreased to 67.86 ml/min (from 200 ml/min at 60 min), with greatly reduced adsorption capacity of CytoSorb® after 8 h. A loading dose (additional 600 mg) would have been urgently needed. Linezolid therapy under hemadsorption with CytoSorb® requires a clear indication and close monitoring of levels to avoid underdosing.

Mortality and adverse events of hemoadsorption with CytoSorb® in critically ill patients: A systematic review and meta‐analysis of randomized controlled trials

“…Third, the device may adsorb various drugs, such as some antibiotics, antimycotics or antivirals. [49][50][51][52][53] An in vitro study suggested the need for administration of an additional antibiotic dose within the first few hours of CytoSorb ® treatment and for early therapeutic drug monitoring since all antimicrobial drugs tested were adsorbed by the cartridge in relevant amounts. 49 However, reliable quantitative clinical data is needed to confirm these findings.…”

The Effects of Hemoadsorption on the Kinetics of Antibacterial and Antifungal Agents

“…Khöler et al measured the blood levels of linezolid given as a 60 min infusion at different time points (before, 15, 60, 120 and 480 min) in a postoperative patient treated with Cytosorb ® and demonstrated that the blood levels after 8 h were below the therapeutic range [ 27 ].…”

Therapeutic Modulation of the Host Defense by Hemoadsorption with CytoSorb®—Basics, Indications and Perspectives—A Scoping Review

“…An additional dose has been recommended for fluconazole and linezolid only [ 160 ]. First clinical data for linezolid suggest similar behavior in humans [ 159 ]. Due to the initial high volume of distribution and the decrease in clearance within a few hours after CytoSorb ® installation, various authors recommend an additional anti-infective dose per adsorber for a variety of antibiotics [ 127 , 141 , 159 , 170 ].…”

“…First clinical data for linezolid suggest similar behavior in humans [ 159 ]. Due to the initial high volume of distribution and the decrease in clearance within a few hours after CytoSorb ® installation, various authors recommend an additional anti-infective dose per adsorber for a variety of antibiotics [ 127 , 141 , 159 , 170 ]. Drug monitoring under hemoadsorption therefore seems to be essential [ 160 ].…”