Meropenem Exposure During Extracorporeal Membrane Oxygenation: What Should Intensivists Know? A Scoping Review.

Abstract

BackgroundExtracorporeal membrane oxygenation (ECMO) is increasingly used in adults with severe respiratory and/or cardiac failure. Because ECMO may alter drug pharmacokinetics (PK), optimizing antimicrobial dosing in this population remains challenging. Meropenem is widely administered in intensive care units (ICUs), yet its disposition during ECMO is not fully understood. This scoping review aimed to characterize population PK methodologies and synthesize current evidence on meropenem pharmacokinetics and pharmacodynamics (PK/PD) in critically ill adults receiving ECMO.MethodsA scoping review was conducted according to PRISMA-ScR guidelines. Studies reporting population PK and/or PD data for meropenem in adult ICU patients undergoing ECMO were included. Systematic searches were performed in Embase, PubMed, LILACS, ProQuest, Web of Science, and Scopus for publications between January 1, 2012, and December 31, 2022. Two independent reviewers screened and selected eligible studies.ResultsEleven studies, including observational cohorts, case series, and simulation-based analyses, met inclusion criteria. Across studies, glomerular filtration rate (GFR) and renal replacement therapy (RRT) were the principal determinants of meropenem clearance, whereas ECMO had a comparatively limited direct effect. Although ECMO may transiently increase volume of distribution and promote early drug sequestration within the circuit, these effects were generally outweighed by renal function parameters. Standard dosing regimens frequently failed to achieve pharmacodynamic targets (fT > MIC ≥40-100%), particularly in patients with augmented renal clearance (ARC). Prolonged or continuous infusions combined with therapeutic drug monitoring (TDM) were consistently associated with improved target attainment.ConclusionsIn ECMO-supported critically ill adults, meropenem exposure is driven predominantly by residual renal function, RRT, and ARC rather than ECMO itself. Individualized dosing strategies incorporating PK modeling and TDM are essential to optimize therapy. Prospective, standardized studies are needed to refine dosing recommendations in this complex population.