Related Experiment Video
Updated: Apr 16, 2026
Multiplex Therapeutic Drug Monitoring by Isotope-dilution HPLC-MS/MS of Antibiotics in Critical Illnesses
Published on: August 30, 2018
A Pilot Study of Cefepime and Meropenem Therapeutic Drug Monitoring in Pediatric Patients on Extracorporeal Therapy
Kaitlin M McFarland1, Christina J Smith1, Sai Karwande1
1Department of Pharmacy, Seattle Children's Hospital, Seattle, WA.
Insights
Pediatric patients on extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT) often have supratherapeutic cefepime levels, especially after CRRT pauses. Meropenem levels remained within goal ranges.
Area of Science:
- Pharmacokinetics and Drug Dosing
- Pediatric Critical Care
- Antibiotic Therapy
Background:
- Patients on extracorporeal therapy experience pharmacokinetic shifts.
- Limited data exist on antibiotic dosing for pediatric patients on ECMO or CRRT.
- Cefepime and meropenem troughs are frequently outside goal ranges in these patients.
Purpose of the Study:
- To identify patterns between clinical factors, extracorporeal modalities, and cefepime/meropenem serum trough concentrations.
- To investigate antibiotic dosing in critically ill pediatric patients requiring extracorporeal support.
Main Methods:
- Retrospective chart review of pediatric patients on ECMO or CRRT with cefepime/meropenem serum concentrations.
- Analysis of clinical circumstances and drug trough concentrations.
- Descriptive statistics to identify subgroups with out-of-range concentrations.
Main Results:
- Cefepime troughs frequently exceeded goal ranges, particularly in patients on CRRT (92.9%) and ECMO (50%).
- Meropenem troughs were generally within goal ranges regardless of extracorporeal therapy.
- Concentrations exceeded goals after CRRT pauses; one potential neurotoxic event noted with cefepime.
Conclusions:
- Standard cefepime dosing often results in elevated troughs in pediatric patients on CRRT/ECMO.
- CRRT pauses must be considered when dosing cefepime and meropenem.
- Awareness of elevated cefepime levels is crucial for safe antibiotic administration.
Objective:
Patients on extracorporeal therapy receiving medications have the potential for large pharmacokinetic shifts. Data supporting dose adjustments for antibiotics in pediatric patients on extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT) are limited. Institutional data reveal that cefepime and meropenem troughs are often outside of goal ranges for patients on extracorporeal therapies. The objective of this research was to elucidate potential patterns between clinical characteristics, extracorporeal modalities, and total serum trough concentrations of cefepime and meropenem.
Methods:
This retrospective chart review evaluated all patients during the study period with a cefepime or meropenem serum concentration obtained while on ECMO or CRRT. Clinical circumstances were reported, and descriptive statistics were performed on various subgroups to determine which subpopulations experienced more out-of-range drug trough concentrations.
Results:
Twenty-one cefepime serum trough concentrations were reviewed for 11 patients, with the mean and median concentrations exceeding the pre-defined goal range. Fifty percent of serum cefepime concentrations from 6 patients on ECMO were supratherapeutic, whereas 92.9% of serum cefepime concentrations from 7 patients on CRRT were supratherapeutic. Seven serum meropenem concentrations were reviewed for 5 patients, and the mean, median, and IQR of the serum troughs were all within goal range, regardless of extracorporeal therapy used. All cefepime and meropenem serum trough concentrations that were collected after a pause in CRRT of at least 1 hour within the previous 24 hours exceeded the goal ranges. One possible neurotoxic event was identified in a patient receiving cefepime and CRRT.
Conclusions:
Pharmacists and providers should ensure that pauses in CRRT are accounted for when dosing these antibiotics and should be aware that standard cefepime dosing for these patients often leads to elevated trough concentrations.
Related Concept Videos
01:26Extracorporeal Removal of Drugs: Continuous Renal Replacement Therapy
01:26Pharmacokinetics in Pediatric Patients: Drug Excretion
01:24Pharmacokinetics in Pediatric Patients: Drug Metabolism
01:25Extracorporeal Removal of Drugs: Hemoperfusion and Hemofiltration
01:16Therapeutic Drug Monitoring: Overview and Classification
01:29Therapeutic Drug Monitoring: Affecting Factors