Adequate Antimicrobial Dosing in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation: Where to Go from Here?

Antimicrobial dosing is a challenge for patients receiving extracorporeal membrane oxygenation (ECMO) and there are currently no guidelines on antimicrobial dosing for these patients due to the heterogeneous and often conflicting body of evidence. The Antibiotic, Sedative and Analgesic Pharmacokinetics during Extracorporeal Membrane Oxygenation (ASAP-ECMO) study has investigated the impact of ECMO on antimicrobial exposure, finding that a large variability in all PK parameters was found, with subtherapeutic exposure as the main problem. Poor target attainment was most frequently found for oseltamivir, piperacillin, and vancomycin. Although the results of the study are worrying, they are also reassuring as PK estimates of most antimicrobials were comparable to previously published data in ICU patients without ECMO support. However, it is not clear whether an increase in PK variability related to ECMO cannot be differentiated from the large PK variability associated with critical illness itself.