Pharmacokinetics of unbound linezolid in plasma and tissue interstitium of critically ill patients after multiple dosing using microdialysis

Abstract

The antimicrobial agent linezolid is approved for the treatment of severe infections caused by, e.g., methicillin-resistant Staphylococcus strains. In order to evaluate the penetration of linezolid into the interstitial space fluid (ISF) of subcutaneous adipose tissue and skeletal muscle of the target population, a microdialysis study was performed with 12 patients with sepsis or septic shock after multiple intravenous infusions. Unbound linezolid concentrations were determined for plasma and microdialysates by use of a validated high-performance liquid chromatography method. Individual compartmental pharmacokinetic (PK) analysis was performed using WinNonlin. In vivo microdialysis was found to be feasible for the determination of unbound linezolid concentrations at steady state in the ISF of critically ill patients. On average, linezolid showed good distribution into ISF but with high interindividual variability. A two-compartment model was fitted to unbound concentrations in plasma with a geometric mean distribution volume of 62.9 liters and a mean clearance of 9.18 liters/h at steady state. However, disposition characteristics changed intraindividually within the time course. In addition, an integrated model for simultaneous prediction of concentrations in all matrices was developed and revealed similar results. Based on the model-predicted unbound concentrations in ISF, a scheme of more-frequent daily dosing of linezolid for some critically ill patients might be taken into consideration to avoid subinhibitory unbound concentrations in the infected tissue. The developed integrated model will be a valuable basis for further PK data analysis to explore refined dosing guidelines that achieve effective antimicrobial therapy in all patients by use of the population PK approach.

FIG. 1.

Geometric means of observed unbound linezolid concentrations in plasma (filled diamonds, solid line), s.c. ISF (open squares, dashed line), and i.m. ISF (crosses, dotted line) of septic patients (n = 6 to 10) after multiple i.v. dosing. Error bars represent the geometric standard deviations.

FIG. 2.

Intraindividual changes in PK of unbound linezolid in plasma from single dosing (left) to steady state (right). Model-predicted concentrations based only on single-dose data are represented by the solid line, observed concentrations by filled diamonds. See text for details.

FIG. 3.

Individual changes in clearance and volume of distribution of unbound linezolid in plasma after multiple i.v. dosing of 600 mg twice a day (each symbol represents the estimated parameter value for one patient).

FIG. 4.

Structure of the integrated pharmacokinetic models for simultaneous modeling of unbound plasma and s.c. and i.m. ISF data after multiple dosing of linezolid (see text for details).

FIG. 5.

Model-predicted concentration-time profile of a representative patient after multiple linezolid dosing.

FIG. 6.

Goodness of fit of the integrated PK model after multiple i.v. dosing showing the unbound model-predicted data versus observed data from the three matrices plasma (filled diamonds), s.c. ISF (open squares), and i.m. ISF (crosses) (n = 9). The solid line represents the line of identity.

FIG. 7.

Observed concentration-time plot of a patient with impaired drug distribution into tissue interstitium after single and multiple dosing of linezolid.