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Journal of the Formosan Medical Association xxx (xxxx) xxx

Available online at www.sciencedirect.com

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journal homepage: www.jfma-online.com

Original Article

Impact of high plasma concentrations of

linezolid in Taiwanese adult patientsd
therapeutic drug monitoring in improving
adverse drug reactions
Chih-Ning Cheng a, Chien-Chih Wu b,c, Ching-Hua Kuo b,c,
Chi-Chuan Wang a,b,c, Jann-Tay Wang d, Ya-Ting Lin a,c,
Ren-Shiang Jhang c, Shu-Wen Lin a,b,c,*

a
Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei,
Taiwan
b
Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
c
School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
d
Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University
Hospital, Taipei, Taiwan

Received 20 January 2020; received in revised form 19 May 2020; accepted 9 June 2020

KEYWORDS Background: Previous studies have shown that the development of thrombocytopenia was
Linezolid; associated with the elevated plasma concentration of linezolid, but little is known about
Therapeutic drug the relationship between other uncommon adverse drug reactions (ADRs) and plasma concen-
monitoring; tration. The appropriate dosing adjustment has remained controversial. This prospective
Dosing adjustment; observational study was conducted to investigate the association between the plasma concen-
Lactic acidosis; tration of linezolid, ADRs, and clinical outcomes.
Thrombocytopenia Methods: Adult patients on linezolid treatment undergoing at least one therapeutic drug moni-
toring (TDM) were enrolled. The association between linezolid concentrations and ADRs was
examined by multivariate Cox regression model. Predictors of linezolid concentrations was
determined by linear regression model. The cut-off point of linezolid concentration and the
effect of dosing adjustments based on TDM was also explored.
Results: Of 50 patients enrolled in the study, plasma concentrations were 1.5e3 times higher
than what was described in the prescribing information. The median minimum concentration
(Cmin) was significantly higher in patients with thrombocytopenia compared to patients without
thrombocytopenia (13.0 vs. 7.2 mg/mL, P Z 0.0273), and a higher median maximum concen-
tration was also observed in patients with lactic acidosis (33.0 vs. 27.5 mg/mL, P Z 0.0420).
The Cmin was elevated in patients with advanced age and severely impaired renal function.

* Corresponding author. Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Room 216, No. 33,
Linsen S. Rd, Taipei, 10050, Taiwan. Fax: þ886 2 33668780.
E-mail address: shuwenlin@ntu.edu.tw (S.-W. Lin).

https://doi.org/10.1016/j.jfma.2020.06.011
0929-6646/Copyright ª 2020, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
 + MODEL
2 C.-N. Cheng et al.

Dosing adjustment tailored by early TDM with the upper limit of Cmin 9 mg/mL may improve
platelet counts.
Conclusion: Elevated linezolid concentrations were associated with thrombocytopenia and
lactic acidosis. TDM-guided dosing adjustment could be considered as a pragmatic way to miti-
gate thrombocytopenia.
Copyright ª 2020, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Introduction determine the optimal cut-off point of linezolid plasma

Linezolid, the first-in-class oxazolidinone antimicrobial
agent, plays an important role in the treatment of
multidrug-resistant Gram-positive pathogens, such as
methicillin-resistant Staphylococcus aureus (MRSA) and
vancomycin-resistant enterococci (VRE).1 It is also an
alternative for the treatment of non-tuberculosis Myco-
bacterium spp (NTM) infection, especially used in out-
patients due to the availability of an oral formulation.2 The
high tissue penetration of linezolid leads to the successful
treatment of pneumonia and skin and soft tissue infections
(SSTIs).3 In clinical practice, linezolid is administered with a
fixed dose (600 mg every 12 h) regardless of body weight
and the renal or hepatic function. However, severe adverse
drug reactions (ADRs), including reversible myelosup-
pression, especially thrombocytopenia, may occur after
treatment continues for more than 2 weeks.4 Rare ADRs, for
example lactic acidosis and peripheral neuropathy, may
develop during long-term use. Previous research has found
that some patients did not recover even after the discon-
tinuation of linezolid.5
Thrombocytopenia is the most common serious linezolid
ADR, and many studies have discussed its association with
linezolid plasma concentrations.6e10 Inconsistent targeted
minimum concentrations (Cmin) varying from 7 mg/mL to
22.1 mg/mL were reported as a safer upper limits of ther-
apeutic index of linezolid.6,8e12 Matsumoto et al. also
explained the relationship in renally impaired patients from
the pharmacokinetics perspective.12 Conversely, the higher
ratio of 24-h area under the plasma-concentration-versus-
time curve to the minimum inhibitory concentration
(AUC24/MIC) in patients has been found to correlate well
with high treatment success for pneumonia and SSTIs as
well as the eradication of microorganisms.13 Several dosing
strategies, such as weight-normalized dosing, models
established by population pharmacokinetics or therapeutic
drug monitoring (TDM), have been established to prevent
the occurrence of thrombocytopenia.11,12,14 However, few
real-world applications of these approaches have been
presented to date. Additionally, the impact of TDM on other
ADRs, the consensus on the targeted concentration, and the
approaches for dosing adjustment remain unclear and
controversial.
This study primarily aimed to investigate the association
between the concentration of linezolid and severe ADRs.
The secondary objective was to find the possible risk fac-
tors which may result in higher concentrations and to
concentration.
Materials and methods
Study population and study design
This prospective observational study was conducted at
National Taiwan University Hospital between December
2016 and May 2017. Adult patients who aged 20 years and
older on linezolid treatment for at least three days were
qualified for TDM. The patients undergoing TDM were all
enrolled in the study and followed until 30 days after the
completion of linezolid treatment. An individual treatment
course was separated from other courses by a linezolid-free
period of 30 days or more. Each enrolled patient was
sampled after initiating linezolid treatment for at least
three days when the plasma concentration was expected to
reach the steady state. Blood samples were drawn before
the dose (trough concentration) and after the administra-
tion of the next dose (peak concentration). The latter
occurred no less than 2 h after the oral tablet or 30 min
after the end of intravenous (IV) infusion which usually
lasted for 2 h. Nurses who drew the blood were requested
to document the exact sampling time in relationship to the
administration time of linezolid and how long they actually
infused the drug for patients. Peak and trough concentra-
tions were measured by high-performance liquid
chromatography-ultraviolet (HPLC-UV). First order elimi-
nation was assumed to calculate the Cmin, the lowest con-
centration during the dosing interval, and the maximum
concentration (Cmax), defined as 2 h after the oral tablet or
right at the end of IV infusion. The trapezoid method was
used to calculate the 24-h area under the curve (AUC24).15
These concentrations were utilized to correlate with the
ADRs and clinical outcome. The weekly TDM results were
also reported to the medical teams to facilitate clinical
decisions for patient care.
The safety outcomes were assessed throughout the
treatment course until 7 days after the completion of
linezolid treatment. Severe ADRs, such as myelosuppression
(including thrombocytopenia, anemia, and leukopenia),
lactic acidosis, and peripheral neuropathy, were observed
in this study. All ADRs were evaluated with the Naranjo
scale, and only the possible/probable/definite ADRs (Nar-
anjo scale  1 point) were accounted for in the analyses of
ADRs.16 The clinical outcome was assessed throughout the

Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
 + MODEL
Impact of high LZD concentration and effect of TDM
treatment course until 30 days after the completion of
linezolid treatment. This study was approved by the NTUH
Research Ethics Committee, and the trial information was
posted on the Clinicaltrials.gov website (NCT03126890).
Informed consent was obtained from all individual
participants included in the study.
Measurement of linezolid plasma concentration
All the blood samples were collected in an ethylene
diamine tetra-acetic acid tube and centrifuged for plasma
stored at 80  C. The plasma concentration analysis used a
modified HPLC method.17 Briefly, 600 mL acetonitrile was
added to 200 mL plasma for extraction and then centrifuged
at 13,200 rpm for 10 min. The supernatant was separated
and dried with nitrogen. After reconstitution with 50%
methanol, the solution was filtrated and injected into a
HPLC-UV system (Hitachi, Tokyo, Japan). The injected
volume of each sample was 5 ml, and the UV detection was
set at 250 nm.
The analytical conditions were as follows: an analytical
Luna C18 column (4.6 mm  250 mm, 5 mm, Phenomenex,
Torrance, CA, USA) was used. The mobile phase comprised
acetonitrile and 0.01 M formic acid buffer (pH 3.3) with a
gradient condition, and the flow rate was 1 mL/min. The
calibration curve was established (concentration range:
1e80 mg/mL), and the corresponding determination coeffi-
cient (R2) was calculated by simple linear regression. The
lower limit of detection and limit of quantification were 0.5
and 1 mg/mL, respectively. Intra-day and inter-day precision
were within 5% and 15%, respectively. Accuracy was around
100  5% for all concentrations in the calibration curve,
except the lower limit of quantification, which was around
100  15%. All the analytical methods were conducted in
accordance with U.S. Food and Drug Administration guidance
regarding bioanalytical method validation.18
Outcome definition
In patients with normal baseline counts, thrombocytopenia
was defined as platelets <75% of baseline or <100,000/ml,
anemia as hemoglobin <75% of baseline or <10 g/dL, and
leukopenia as white blood cells <50% of baseline or <3500/
ml. Both criteria were required for individual ADRs in patients
with an abnormal baseline. Lactic acidosis was defined as
lactate over 4 mmol/L during the course of treatment.19
Peripheral neuropathy was defined by diagnosis or a pa-
tient’s clinical symptoms, such as numbness or a stinging or
itching sensation, according to medical records.
The clinical outcome was classified into 4 categories:
improvement (microbiological eradication or the resolution
of infection signs and symptoms); failure (persistent posi-
tive culture with GPC or NTM, or deteriorated signs and
symptoms of infection); death caused by GPC or NTM; or
other causes of death.
Covariates
All patients’ data were retrieved through electronic medi-
cal charts, including the patient’s demographics, ICU
admission, laboratory data, infection associated
Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
3
information, and primary underlying disease. The severity
of patients’ infection was assessed by the Sequential Organ
Failure Assessment (SOFA) score.20,21 Comorbidities which
may influence the plasma concentrations and outcome
were recorded as follows: severe renal impairment,
cirrhosis, chronic heart failure, decompensated heart fail-
ure, diabetes mellitus, acute respiratory distress syndrome,
and bleeding. Charlson’s Comorbidity Index was used to
evaluate the effect of chronic disease. The co-medications,
including clarithromycin, erythromycin, rifampin, rifabu-
tin, phenytoin, levothyroxine, vitamin B complex, amio-
darone, amlodipine, omeprazole, esomeprazole, and total
parenteral nutrition, were also retrieved to investigate the
association with linezolid concentrations.
Statistical analyses
The first TDM report of each patient was utilized to depict the
plasma concentration distribution in different treatment
regimens. The first TDM report of each treatment course was
included in the concentration analysis. To obtain fair com-
parison and to eliminate the immortal time bias, the analysis
of the association between plasma concentrations and out-
comes was restricted to the linezolid recent users, whose
TDM was performed within 14 days after initiating linezolid.
Patients who received a baseline blood transfusion, platelet
transfusion or granulocyte colony-stimulating factor were
further excluded in the analysis of concentrations and
myelosuppression, because these procedures might have
obscured the cause of the study outcome. Patients without
any lactate level were also excluded from the analysis of
concentrations and lactic acidosis. The ManneWhitney U
test was used to compare the concentration among the pa-
tients with or without ADRs or with different clinical out-
comes. To account for the different times for developing
ADRs and to reduce other potential biases, the associations
between concentrations and ADRs were further adjusted by
the multivariate Cox proportional hazard model, and the
covariates included in the regression were selected accord-
ing to the univariate Cox model.
Simple and multiple linear regression determined the
factors that might greatly influence linezolid concentra-
tions. All the independent factors included in the multiple
regression were selected based on the results of a univar-
iate regression. The linezolid cut-off point was calculated
by the receiver operating characteristic (ROC) curve with
2000 times bootstraps to identify which concentration
might develop thrombocytopenia. The statistical analyses
were performed with SAS 9.4 version (SAS Institute Inc.,
Cary, NC, USA).
Results
Patient demographics
Of 50 patients enrolled in the study, there were 52 linezolid
treatment courses (two patients had two treatment courses
in this analysis). Their baseline characteristics and infection
status are presented in Table 1. Their average body weight
was 59.3  14.8 kg, with body mass index of 22.7  4.8 kg/m2.
Sixteen patients (32%) had severe renal impairment,
 + MODEL
4 C.-N. Cheng et al.

Table 1 Demographics and clinical characteristics. Table 1 (continued )

Demographics - mean  SD Total patients (n Z 50) Demographics - mean  SD Total patients (n Z 50)
Age (years) 61.5  16.9 Vancomycin-resistant 16 (30.8)
No. of males (%) 24 (48.0) enterococci
No. of inpatient (%) 44 (88.0) Non-tuberculosis 10 (19.2)
No. of ICU admission (%) 21 (42.0) Mycobacterium spp.
Weight (kg) 59.3  14.8 Others (Coagulase- 4 (7.7)
Body-mass index (kg/m2) 22.7  4.8 negative staphylococci,
Laboratory dataa - median (interquartile range, IQR) vancomycin-susceptible
Serum creatinine (mg/dl) 0.9 (0.6e2.6) Enterococcus faecalis)
Creatinine clearance 61.3 (18.0e105.8) a
Number of patients with the following laboratory data: ALT
(ml/min)b
(n Z 43); T-bil (n Z 29); Alb (n Z 29); INR (n Z 29); CRP
Alanine aminotransferase 23.0 (11.0e31.0) (n Z 36).
(ALT, U/l) b
CLcr. < 15 mL/min (n Z 12).
Total bilirubin (mg/dl) 0.6 (0.5e0.7) c
Each treatment course may include more than 1 indication.
Albumin (g/dl) 3.1 (2.4e3.5) d
Lymph node infection (n Z 1), peritonitis (n Z 1), neck
International normalized 1.05 (0.95e1.18) lymphadenitism (n Z 1), peritonitis (n Z 1), meningitis (n Z 1),
ratio (INR) liver abscess (n Z 1), endocarditis (n Z 1), sepsis without
C-reactive protein (CRP, 4.2 (1.1e10.1) specific origin (n Z 1).
mg/dl)
Comorbidities eno. (%)
Severe renal impairment 16 (32.0) including stage 4 (n Z 1) or stage 5 chronic kidney disease
Cirrhosis 1 (2.0) (n Z 7), or acute kidney injury (n Z 8), when the TDM was
Chronic heart failure 5 (10.0) performed. The main indications for linezolid use were
Decompensated heart 3 (6.0) pneumonia (42.3%) and SSTIs (28.8%) with multiple drug-
failure resistant pathogens such as MRSA (42.3%) and VRE (30.8%).
Diabetes mellitus 11 (22.0) Twenty-three treatment courses (44.2%) used other antibi-
Acute respiratory distress 6 (12.0) otics simultaneously. The concentration distribution of the
syndrome first TDM showed high variability among different patients in
Bleeding 26 (52.0) all dosing regimens (Supplementary 1).
Charlson’s Comorbidity 3 (1e4)
Index - median (IQR)
Hemodialysis eno. (%) 11 (22)
Evaluation of safety and clinical outcomes and
associations with plasma concentrations
Treatment and Infection Total treatment course
status (n [ 52)
A total of 41 treatment courses (78.8%) reported major
Treatment duration (days) e median (IQR) ADRs, such as thrombocytopenia, anemia, leucopenia,
Total daily dose of 14 (9e19) lactic acidosis, and peripheral neuropathy. Thrombocyto-
1200 mg (n Z 45) penia was the most common ADR (61.5%), followed by
Total daily dose of 600 mg 98 (26e207) leukopenia (30.8%), anemia (26.9%), lactic acidosis (25.0%),
(n Z 7) and peripheral neuropathy (5.8%). All the ADRs were cate-
SOFA score on start date - 3 (0e7.5) gorized as at least having possible causality based on the
median (IQR) Naranjo scale, and half the thrombocytopenia events were
Indicationsc e no. (%) determined as probable or definite. The onset of ADRs
Pneumonia 22 (42.3) occurred mostly after continuous use of linezolid for 2
Skin and soft tissue 15 (28.8) weeks to 1 month. All patients recovered within 1e2 weeks
infections upon discontinuing linezolid, except 3 patients with pe-
Bone and joint infections 8 (15.4) ripheral neuropathy that lasted for at least 3 months.
Catheter-related blood 5 (9.6) The number of treatment courses included in the anal-
stream infections ysis between concentrations and each ADR shows in Fig. 1.
Cystitis 3 (5.8) Peripheral neuropathy was excluded from the analysis since
Brain abscess 2 (3.8) all the patients diagnosed with peripheral neuropathy did
Othersd 8 (15.4) not have TDM within 14 days after initiation of linezolid. As
Pathogens e no. (%) displayed in Fig. 2, the median Cmin and AUC24 was signifi-
Staphylococcus aureus 23 (44.2) cantly higher in the patients who experienced thrombocy-
Methicillin-resistant S. 22 (42.3) topenia (Cmin: P Z 0.0273; AUC24: P Z 0.0250) and median
aureus Cmax was also significantly elevated in patients with lactic
Methicillin-susceptible 1 (1.9) acidosis (P Z 0.0420). No significant association was iden-
S. aureus tified between plasma concentrations and anemia or
leukopenia. The associations between plasma concentra-
tions and ADRs were further examined by the multivariate

Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
 + MODEL
Impact of high LZD concentration and effect of TDM 5

Figure 1 Flow chart of included treatment courses in the analysis of concentration and ADRs. Peripheral neuropathy was
excluded in the analysis since all patients suffered from peripheral neuropathy received TDM over 14 days after initiation of
linezolid.

Cox proportional hazard model. Linezolid Cmin remained a
significant predictor of the occurrence of thrombocyto-
penia (hazard ratio: 1.06, 95% confidence interval [CI]
1.01e1.11, P Z 0.0133), after adjustment for severe renal
impairment and use of clarithromycin. When the Cmin rose
from 10 to 20 mg/mL, the risk of thrombocytopenia
increased 1.808 (Z[1.061]10) fold. However, Cmax did not
significantly predict the incidence of lactic acidosis in the
multivariate Cox regression model.
Of 52 treatment courses, the clinical outcomes in 32
courses (61.5%) were improved. The mortality rate was
21.2%, with 7.7% due to Gram-positive cocci (GPC) or NTM
infections and 13.5% due to other causes. The median
AUC24/MIC was 264.3 mg/ml/hr (185.4e456.3) in 28 patients
with improved infections and 375.8 mg/ml/hr (281.1e572.9)
in 13 patients with treatment failure or death due to in-
fections. The association between AUC24 and clinical out-
comes was not significant (P Z 0.1571).
weight, SOFA score at linezolid start date, and existence of
severe renal impairment (Table 2). Only age and severe
renal impairment significantly affected the Cmin, and this
model could explain 41.24% of the Cmin variance of line-
zolid. Even though only one patient had liver cirrhosis, the
severe hepatic impairment might have substantially
affected the concentrations by decreasing the metabolism
of linezolid, and thus we included this factor in the
regression model to re-evaluate the potential factors pre-
dicting Cmin. The results showed that the addition of liver
cirrhosis greatly increased the model explanation of Cmin to
57.29%. The mean cut-off point of Cmin to predict the
occurrence of thrombocytopenia was 9.2 mg/mL (95% CI:
9.1e9.4 mg/mL). The positive predicted value and negative
predicted value were 69.6% and 44.8%, respectively.
Effect of dosing adjustment

Five patients repeated TDM after linezolid dosing regimens

Factors to predict Cmin and the cut-off point were modified. The concentration patterns are illustrated
in Fig. 3 (a). The Cmin decreased disproportionally when the
We further investigated the factors that might affect Cmin. dose was reduced with the same dosing frequency. For
Factors in the multiple linear regression included age, body example, Cmin changed disproportionally from 8.97 mg/mL

Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
 + MODEL
6 C.-N. Cheng et al.

Figure 2 Distribution of linezolid concentrations in patients with or without experiencing ADRs. The presented value is the
median concentration of each group. The ManneWhitney U test and the non-parametric statistic method were used since all Cmin
and Cmax were not normally distributed.

to 4.68 mg/mL (patient E) with the dose reduction from times higher compared to the manufacturer’s prescribing in-
600 mg to 400 mg twice daily. A more significant decline, formation.22 A similar or even higher median Cmin
from 12.28 mg/mL to 2.46 mg/mL, was observed when the (7.0e21.7 mg/mL) has also been observed in Japanese pa-
dose was reduced from 600 mg to 400 mg daily (patient C). tients; on the contrary, an Italian study reported low Cmin
When the same dose administered twice daily was changed (3.8 mg/mL), which was consistent with the data in the pre-
to once daily, the extent of the Cmin decrease exceeded scribing information.6e8,10 Two potential explanations can be
more than half (patient A, B, and C). In addition, the provided regarding the difference. First, patients’ renal
plasma concentration of oral administration was only function may play an important role in plasma concentra-
approximately 60% of the concentration resulted from IV tions, and our study confirmed that creatinine clearance was
infusion in one patient (patient D). a significant predictor of Cmin. Linezolid is partially excreted
Twelve out of 23 patients who developed thrombocyto-
penia had at least one platelet count result within seven
days after discontinuation of linezolid (n Z 7) or dosing
adjustment (n Z 5). Fig. 3 (b) illustrates the changes of Table 2 Multivariate analysis of potential factors in pre-
platelet in relative to baseline level with discontinuation of dicting linezolid Cmin.
linezolid or dosing reductions. Most patients suffered from Variable Coefficient 95% CI P value
thrombocytopenia which decreased to less than half of the
baseline platelet value. The trends of platelet changes in Age (yr) 0.242 0.120, 0.364 0.0003
both groups were similar, and platelet levels returned to Body weighta 1.014 5.633, 3.605 0.6594
the baseline approximately seven days after discontinua- Severe renal 9.821 4.265, 15.378 0.0010
tion or dosing adjustment. impairmentb
SOFA scorec 5.081 10.876, 0.714 0.0839
2
Note. Adjusted r : 0.4124.
Discussion
a
Body weight was classified into 60 kg or not.
b
Severe renal impairment included stage 4, 5 CKD or AKI.
c
SOFA score at linezolid start date was classified into 3 or
This prospective observational TDM study demonstrated that not.
the average linezolid concentration of 12.1 mg/mL was 1.5e3

Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
 + MODEL
Impact of high LZD concentration and effect of TDM 7

Figure 3 Cmin and platelet count changes after dosing adjustment or discontinuation of linezolid. (a) Cmin after dosing adjust-
ment. Steady-state Cmin of 5 patients wasmeasured and labeled. (b) Comparison of platelet changes in patients developing
thrombocytopenia e discontinuation (left) vs. dosing adjustment (right). The results display the trend of platelet changes (relative
to baseline platelet counts) after initiation of linezolid among patients developing thrombocytopenia. Patient#1 to Patient#7
discontinued linezolid (left), while Patient#8 to Patient#12 reduced linezolid doses (right).

through the kidneys, and impaired renal function may result
in high plasma concentrations due to the accumulation of
linezolid.6 The pharmacokinetic studies in the prescribing
information generally enrolled normal patients and healthy
volunteers; however, patients participating in the Japanese
study had worse creatinine clearance (49.4e78.5 mL min1)
than those in the Italian studies or prescribing
information.6e8,10 In addition, a recent study with only 3.3% of
patients receiving renal replacement therapy also showed
lower Cmin (2.9 mg/mL).23 In the present study about 32% of
patients had lower creatinine clearance (<30 mL/min), and
22% of patients received renal replacement therapy, which
explains why high concentrations were observed.
Body weight may be another possible reason for the
difference. In previous studies, the Western population
usually displayed a larger volume distribution (Vd) due to

Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
 + MODEL
8 C.-N. Cheng et al.
higher body weight, resulting in a lower plasma concen-
tration (Dose Z C x Vd). The patients in the Italian
study had higher weights than Japanese subjects or the
patients in this study, which was in line with our assump-
tions. Although body weight was not a significant
predictor of Cmin in our study, a body weight-adjusted daily
dosage was recommended in a retrospective study for
the possible risk factor of linezolid-associated
thrombocytopenia.14
Our results indicated that a higher plasma concentration
was associated with the development of thrombocytopenia.
This was consistent with previous studies6,8e12; however,
we used a more delicate definition to align with the clinical
concept of the occurrence of thrombocytopenia. Throm-
bocytopenia was defined in patients with abnormal base-
lines of platelets if they met both criteria regarding
platelet counts: < 75% of the baseline and <100,000/ml,
simultaneously. Platelet counts may decrease in critically
ill patients and the fluctuation has been sometimes
observed.24 The loss of platelets might not cause immedi-
ate danger unless the count is below 20,000/ml.25 However,
a significant drop of platelets in patients with normal
baselines would be considered a clinically unusual event,
upon which action should be taken, so thrombocytopenia
was considered if either criterion was fulfilled. Addition-
ally, the multivariate Cox regression model was applied,
and a high plasma Cmin was the only predictor of linezolid-
related thrombocytopenia under adjustment of con-
founders, further confirming our findings and the impor-
tance of TDM in clinical practice.
The present study shows that patients with lactic
acidosis tended to have higher Cmax, which has not been
previously reported. Lactate is metabolized to pyruvate in
liver mitochondria through the Cori cycle.26,27 Linezolid
also targets human mitochondrial ribosomes, which might
interfere with the lactate metabolism.28 Although it
seemed that plasma concentration was not a risk factor of
lactic acidosis in this study after adjustment in the multi-
variate Cox regression, it merits a larger sample size to
investigate this association. The risk factor that may pre-
cipitate linezolid-associated lactic acidosis remains un-
known, except for the prolonged use of linezolid.19 While
most cases in the present study occurred after continuous
use of linezolid for 2e3 weeks, which was relatively faster
than in the normal population,29 the effect of high linezolid
concentrations and presence of renal impairment or sepsis
could not be completely ruled out.30 Further research is
needed to explore the correlation.
Lactic acidosis was as high as 25% among the ADR in this
study. Generally, lactate is not a routine laboratory
parameter in clinical practice in Taiwan, and the symptoms
of lactic acidosis might present as nausea and vomiting
which are usually unspecific. On the other hand, lactate is
monitored more closely in patients in critical conditions.
The higher event rate of lactic acidosis in our study could
be explained by the enrollment of many critically ill pa-
tients. There were 42% of patients admitted to ICU in this
medical center, indicating a high disease severity of the
study population. Im et al. reported that linezolid-
associated lactic acidosis was approximately 6.8%.19 The
median of length of stay in the study, 14 days, was much
shorter than which in our study (41 days). Caution should be
Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
exercised when one compares this study result to others
due to different patient populations.
In contrast to previous studies,3,13 linezolid concentra-
tions were not associated with clinical outcomes in the
present study. Higher plasma concentrations in the Staph-
ylococcus eradication group were observed, and an AUC24/
MIC over 120 mg/ml/hr achieved an 80% eradication rate in
a previous prospective study.13 However, in our results, the
median AUC24/MIC in both outcome improvement or failure
groups was over 120 mg/ml/hr. Under an adequate con-
centration, the clinical outcome might be affected by other
factors, such as co-morbidities or severity of infection. The
effect of other antibiotics on the clinical outcome cannot
be precluded since linezolid is usually preserved as an
alternative treatment in Taiwan.
The change of plasma concentration after the dosing
adjustment followed a non-linear pattern in our observa-
tion. One review article has mentioned that linezolid ex-
hibits metabolic nonlinearity, and clearance may decrease
30% when the dose increases fivefold.31 The inhibition of
clearance was also observed in a pharmacokinetic study,
and the self-inhibition of linezolid may be the possible
reason.32 It seems that TDM is necessary in this population,
given the unpredictable change of linezolid concentrations
after dosing adjustment. Additionally, the noticeable re-
turn of platelet counts was not only found in patients dis-
continuing linezolid but also in patients reducing doses for
approximately 7 days. The half-life of platelets was about 7
days, so even after dosing adjustment, platelets were still
affected by previous dosing regimens and might not have
recovered instantly. This preliminary result reveals dosing
adjustment guiding by TDM could be an alternative way to
reverse thrombocytopenia, and a recent study also indi-
cated that linezolid-related thrombocytopenia can be
avoided by dose reduction.33 Therefore, timely TDM, dosing
adjustment, if clinically indicated, and close monitoring
after starting linezolid are necessary.
There were some limitations to this study. First, more
patients would be needed to confirm the potential corre-
lation that was observed in this study between linezolid
concentration and other ADRs. Second, the frequency of
monitoring in each patient varied according to their clinical
conditions, due to the nature of the observational study.
Some laboratory data or ADRs may be unavailable or
underreported in our study population, especially in the
outpatient setting. Third, it is impractical to perform the
TDM on a fixed schedule in this study. However, all plasma
concentrations in our study were measured after reaching a
steady state. We also analyzed only the TDM results done
within 14 days after starting linezolid in the concentration
analyses, to minimize the influence of varied sampling
times. Thus, the results of TDM was not associated with
patients’ treatment durations. Forth, some patients
received other antibiotics that may cause the same ADRs as
linezolid did. We have utilized the Naranjo scale to assess
whether the ADR was truly associated with linezolid in this
study. ADRs deemed “possible”, “probable”, and “definite”
were included in the adverse event group, whereas
“doubtful” ADRs were dismissed from analysis. Therefore,
we considered that all the ADRs defined in this study were
associated with linezolid use. Last, only few patients were
collected to indicate the potential effect of dosing
 + MODEL
Impact of high LZD concentration and effect of TDM
adjustment. To understand effectiveness and safety after
dosing adjustments, more TDM studies are warranted to
tailor dosing regimens by cut-off points.
In summary, high plasma concentrations of a standard
dose of linezolid were observed in this study. An elevated
Cmin was associated with thrombocytopenia, and increased
Cmax was also observed in patients with lactic acidosis.
Dosing adjustments tailored by early TDM could be consid-
ered to improve linezolid-associated thrombocytopenia,
especially in patients with renal impairment and the
elderly.
Author Contributions
All authors were responsible for the preparation of the
manuscript. Dr. Lin SW and Dr. Wang JT developed the study
idea. Ms. Cheng CN, Dr. Lin SW, Mr. Wu CC participated in
study design and enrollment of patients. Dr. Kuo CH, Ms. Lin
YT, and Mr. Jhang RS developed the analytical methods. Dr.
Wang CC reviewed the statistical methods. Ms. Cheng CN
also contributed to the measurement of concentrations,
data acquisition, and statistical analysis. Ms. Cheng CN, Dr.
Lin SW, Mr. Wu CC, Dr. Kuo CH, Dr. Wang CC, and Dr. Wang
JT participated in the interpretation of the data. Ms. Cheng
CN contributed to drafting manuscript, and all authors
reviewed and approved the manuscript for submission.
Disclosure of funding
This work was funded by National Taiwan University Hos-
pital (grant numbers 106-08), Taiwan and Ministry of Health
and Welfare and National Taiwan University Infectious
Diseases Research and Education Center.
Compliance with ethical Standard Statement
All procedures performed in studies involving human par-
ticipants were in accordance with the ethical standards of
the institutional and/or national research committee
(NTUH Research Ethics Committee 201610008RINB) and
with the 1964 Helsinki declaration and its later amend-
ments or comparable ethical standards. Informed consent
was obtained from all individual participants included in
the study.
Disclosure of Conflict of Interests
All authors declare that they have no competing interests.
Acknowledgement
The authors are grateful to all of the patients for their
participation in this study. Special thanks to Dr. Jann-Yuan
Wang, Dr. Wei-Fang Kao, Mr. Chih-Hsun Tai, Ms. Shin-Yi Lin,
Ms. Yu-Wen Wang, Ms. Pei-Guin Wu, and Mr. Chien-Hao
Chen for patient enrollment.
Please cite this article as: Cheng C-N et al., Impact of high plasma concentrations of linezolid in Taiwanese adult patientsd therapeutic
drug monitoring in improving adverse drug reactions, Journal of the Formosan Medical Association, https://doi.org/10.1016/
j.jfma.2020.06.011
9
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jfma.2020.06.011.
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