Can cytokine adsorber treatment affect antibiotic concentrations? A case report

Sir, Cytokine adsorbers, such as CytoSorb® (CytoSorbents, Monmouth Junction, NJ, USA), play an increasingly important role in the treatment of critically ill patients suffering from excessive inflammatory responses. Cytokine adsorption as a treatment during severe sepsis contains the excessive systemic expression of pro- and anti-inflammatory substances during septic conditions.1 Recently, it has been shown that BetaSorb® (CytoSorbents) removes antibiotics in an in vitro system.2 The removal of vitally important antibiotics by cytokine-adsorbing devices in vivo may result in insufficient and low antibiotic levels and a poor outcome and may finally promote the development of antibiotic resistance. However, to date, no in vivo data are available on the removal of these drugs by a cytokine filter. Here, we report, for the first known time, the use of in vivo pharmacokinetic monitoring of linezolid and meropenem during treatment with CytoSorb®. A patient with septic shock and multiple organ failure was admitted to the ICU at the University Hospital of Munich. The patient's condition was characterized by excessive inflammatory responses, presenting with 1700/μL of leucocytes (reference range 4000–11 000/μL), 46 μg/L of procalcitonin (<0.1 μg/L) and 563 000 ng/L of IL-6 (<5.9 ng/L). An initial laparotomy showed an ischaemic bowel with peritonitis. The patient was immediately given intravenous meropenem (2 g) and underwent a segmental resection of the jejunum and colon with the surgical formation of an ileotransverse colostomy. A culture from an intra-abdominal smear revealed meropenem-susceptible Enterobacteriaceae and a linezolid-susceptible strain of Enterococcus faecalis during the subsequent course of the disease. In addition to meropenem, linezolid treatment was started 5 h after admission. Both antibiotics were administered intravenously with short infusion times (15–60 min). Because of the excessive cytokine storm, adjuvant therapy with an extracorporeal arteriovenous cytokine filter system containing adsorbent polymer beads (CytoSorb®) was initiated (four times within 96 h). The first use of the cytokine filter had to be stopped because a second look surgery was required to achieve haemostasis. Over the following days, the patient's condition substantially improved (i.e. there was an improvement in renal and liver function and cardiorespiratory status, etc.). However, after 4 weeks and seven further repeat laparotomies, the patient died from multiple organ failure.