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Abstract

Introduction

Protocol

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Medicine

Multiplex Therapeutic Drug Monitoring by Isotope-dilution HPLC-MS/MS of Antibiotics in Critical Illnesses

Published: August 30th, 2018

DOI:

10.3791/58148

1Institute of Laboratory Medicine, University Hospital, LMU Munich

Here we present a tandem mass spectrometry-based protocol for the quantification of frequently used antibiotics in intensive care units, namely cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid, and piperacillin.

There is an ever-increasing demand for the therapeutic drug monitoring of antibiotics in many clinical facilities, particularly with regard to the implementation of hospital antibiotic stewardship programs.

In the current work, we present a multiplex high-performance liquid chromatography-tandem mass spectrometry (HPCL-MS/MS) protocol for the quantification of cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid, and piperacillin, commonly used antibiotics in intensive care units. The method was previously comprehensively validated according to the guideline of the European Medicines Agency.

After a rapid sample cleanup, the analytes are separated on a C8 reverse-phase HPLC column within 4 minutes and quantified with the corresponding stable isotope-labeled internal standards in electrospray ionization (ESI+) mass spectrometry in multiple reaction time monitoring (MRM). The presented method uses a simple instrumentation setting with uniform chromatographic conditions, allowing for the daily and robust antibiotic therapeutic drug monitoring in clinical laboratories. The calibration curve spans the pharmacokinetic concentration range, thereby including antibiotic amounts close to the minimal inhibitory concentration (MIC) of susceptible bacteria and peak concentrations (Cmax) that are obtained with bolus administration regimens. Without the necessity of the serum dilution before the sample cleanup, the area under the curve for an administered antibiotic can be obtained through multiple measurements.

Although antibiotics have revolutionized the practice of medicine, severe bacterial infections remain a leading cause of morbidity and mortality in critical illnesses1. In this regard, the prompt administration of a suitable anti-infective in an adequate dosage is of the uppermost importance for disease control2.

A growing body of evidence demonstrates that the empirical treatment with broad-spectrum antibiotics is becoming increasingly problematic with the complexity of patient populations. This is especially true for intensive care units (ICU), where a tremendous inter-individual variability....

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NOTE: It is recommended to work in a fume hood when handling organic solvent, such as methanol. Prepare all buffers and mobile phases in volumetric flasks. If not otherwise specified, the solutions can be stored at room temperature for up to 1 month after preparation.

1. Preparation of the Calibrators and Quality Control Samples

NOTE: A corresponding data analysis sheet for the preparation of stock and spike solutions is given in the Supplemental File.......

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Using the described protocol, a typical chromatogram is depicted in Figure 2. According to the United States Pharmacopeia (USP) chromatography guidelines16, the column dead volume in the present system was determined with ~0.22 mL and the extra-column volume (including the injector, tubing, and connectors) with ~0.08 mL, giving a hold-up volume of ~0.30 mL. The calculated retention factors for all analytes were 2.8 (for cefepime) - 4.2.......

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In this manuscript, we report the protocol for a simple and robust tandem mass spectrometry-based method for the quantification of frequently used antibiotics in ICU19, namely cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid, and piperacillin14. A spreadsheet accompanies the manuscript for the preparation of antibiotic stock solutions, calibrators, and quality controls, taking into account the purity of the antibiotics and the molecular weight of their counterion.......

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The authors thank Dr. Schütze for his help with establishing the presented method and Dr. Zoller for the valuable input regarding the proper calibration range. The authors also acknowledge the technical staff of the mass spectrometry facility.

....

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Name Company Catalog Number Comments
cefepime hydrochloride Sigma-Aldrich 1097636 USP Reference Standard
meropenem trihydrate Sigma-Aldrich Y0001252 EP Reference Standard
ciprofloxacin Sigma-Aldrich 17850
moxifloxacin hydrochloride Sigma-Aldrich SML1581
linezolid Toronto Research Chemicals L466500
piperacillin sodium salt Sigma-Aldrich 93129
cefepime-13C12D3 sulfate Alsachim C1297 Isotope labelled internal standard for cefepime
meropenem-D6 Toronto Research Chemicals M225617 Isotope labelled internal standard for meropenem
ciprofloxacin-D8 Toronto Research Chemicals C482501 Isotope labelled internal standard for ciprofloxacin
moxifloxacin-13C1D3 hydrochloride Toronto Research Chemicals M745003 Isotope labelled internal standard for moxifloxacin
linezolid-D3 Toronto Research Chemicals L466502 Isotope labelled internal standard for linezolid
piperacillin-D5 Toronto Research Chemicals P479952 Isotope labelled internal standard for piperacillin
methanol JT Baker 8402
HPLC grade water JT Baker 4218
formic acid Biosolve 6914132
acetic acid Biosolve 1070501
ammonium formate Sigma-Aldrich 70221-25G-F
tert-Butyl methyl ether Merck 101845
Fortis 3 μm C8 100 * 2.1 mm Fortis F08-020503
Ti-PEEK-encased Prifilter (2 μm) Chromsystems 15011
2795 Alliance HPLC system Waters 176000491
Quattro micro API Tandem Quadrupole System Waters 720000338
QuanLynx 4.1 software Waters / Data evaluation software provided by the mass spectrometer manufacturer

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