Grand RoundsReal-Time Therapeutic Drug Monitoring-Based Pharmacokinetic/Pharmacodynamic Optimization of Complex Antimicrobial Therapy in a Critically Ill Morbidly Obese Patient. Grand Round/A Case StudyCojutti, Pier Giorgio MD, PhD*,†; Carnelutti, Alessia MD‡; Mattelig, Silvia MD§; Sartor, Assunta MD¶; Pea, Federico MD*,†Author Information *Department of Medicine, University of Udine; †Institute of Clinical Pharmacology, Santa Maria della Misericordia University Hospital of Udine, ASUFC; ‡Infectious Diseases Clinic, Santa Maria della Misericordia University Hospital of Udine, ASUFC; §Department of Anesthesia and Intensive Care, Santa Maria della Misericordia University Hospital of Udine, ASUFC; and ¶Laboratory of Clinical Microbiology, Santa Maria della Misericordia University Hospital of Udine, ASUFC, Udine, Italy. Correspondence: Federico Pea, MD, Department of Medicine, University of Udine, and Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, P.le S. Maria della Misericordia 3, 33100 Udine, Italy (e-mail: firstname.lastname@example.org). F. Pea participated in speaker bureau for Angelini, Basilea Pharmaceutica, Gilead, Hikma, Merck Sharp & Dohme, Nordic Pharma, Pfizer, Sanofi Aventis, and Shionogi. and in advisory board for Angelini, Basilea Pharmaceutica, Correvio, Gilead, Hikma, Merck Sharp & Dohme, Nordic Pharma, Novartis, Pfizer, Shionogi and Thermo-Fisher. The remaining authors declare no conflict of interest. Received December 16, 2019 Accepted January 30, 2020 Therapeutic Drug Monitoring: June 2020 - Volume 42 - Issue 3 - p 349-352 doi: 10.1097/FTD.0000000000000740 Buy Metrics Abstract The authors present the case of a critically ill morbidly obese patient (body mass index, 51.2 kg/m2) who suffered from methicillin-resistant Staphylococcus epidermidis, and Candida albicans bloodstream infections. Initial treatment with caspofungin and daptomycin was deemed inappropriate, because blood cultures remained positive for both isolates after 14 days. The clinical pharmacological consultant suggested adding fluconazole and ceftobiprole to the ongoing antimicrobial therapy, and starting a real-time therapeutic drug monitoring program of daptomycin, ceftobiprole, and fluconazole, aimed at optimizing plasma exposures. Punctual minimum inhibitory concentration knowledge on the clinical isolates allowed attainment of the desired pharmacodynamic efficacy targets. Within few days, the patient greatly improved, as blood cultures became negative, and the inflammatory markers decreased to near normal values. This is a proof-of-concept of the importance of a therapeutic drug monitoring-based multidisciplinary approach in the proper management of complex antimicrobial therapy in special populations. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.