Optimization of fluconazole dosing for the prevention and treatment of invasive candidiasis based on the pharmacokinetics of fluconazole in critically-ill patients

J M Boonstra, A G Märtson, I Sandaradura, J G Kosterink, T S van der Werf, D J E Marriott, J G Zijlstra, D J Touw, J W C Alffenaar

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Background: The efficacy of fluconazole is related to the area under the plasma concentration-time curve over the minimum inhibitory concentration of the microorganism. Physiological changes in critically ill patients may affect the exposure of fluconazole and therefore dosing adjustments might be needed. Objective: The aim of this study was to evaluate variability in fluconazole drug concentration in ICU patients and to develop a pharmacokinetic model to support personalized fluconazole dosing. Methods: A prospective observational pharmacokinetic study was performed in critically ill patients receiving fluconazole either as prophylaxis or as treatment. The association between fluconazole exposure and patient variables was studied. Pharmacokinetic modeling was performed with nonparametric adaptive grid (NPAG) algorithm using R package Pmetrics. Results: Data from 33 patients were available for pharmacokinetic analysis. Patients on dialysis and solid organ transplant patients had a significantly lower exposure to fluconazole. The population was best described with a one-compartment model, where the mean volume of distribution was 51.52 L (SD 19.81) and the mean clearance was 0.767 L/h (SD 0.46). Creatinine clearance was tested as a potential covariate in the model, but was not included in the final population model. A significant positive correlation was found between the fluconazole exposure (AUC) and the CminConclusion: Substantial variability in fluconazole plasma concentrations in critically-ill adults was observed, where the majority of patients were underexposed. Fluconazole Cmin TDM guided dosing can be used to optimize therapy in critically ill patients.

Original languageEnglish
JournalAntimicrobial Agents and Chemotherapy
DOIs
Publication statusE-pub ahead of print - 23-Dec-2020

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