1
|
Shen X, Li X, Lu J, Zhu J, He Y, Zhang Z, Chen Z, Zhang J, Fan X, Li W. Population pharmacokinetic analysis for dose regimen optimization of vancomycin in Southern Chinese children. CPT Pharmacometrics Syst Pharmacol 2024; 13:1201-1213. [PMID: 38686551 PMCID: PMC11247118 DOI: 10.1002/psp4.13151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/19/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
Changes in physiological factors may result in large pharmacokinetic variability of vancomycin in pediatric patients, thereby leading to either supratherapeutic or subtherapeutic exposure and potentially affecting clinical outcomes. This study set out to characterize the disposition of vancomycin, quantify the exposure target and establish an optimal dosage regimen among the Southern Chinese pediatric population. Routine therapeutic drug monitoring data of 453 patients were available. We performed a retrospective population pharmacokinetic analysis of hospitalized children prescribed intravenous vancomycin using NONMEM® software. A one-compartment PPK model of vancomycin with body weight and renal functions as covariates based on a cutoff of 2 years old children was proposed in this study. Both internal and external validation showing acceptable and robust predictive performance of the model to estimate PK parameters. The value of area under the curve over 24 h to minimum inhibitory concentration ratio (AUC0-24/MIC) ≥ 260 was a significant predictor for therapeutic efficacy. Monte Carlo simulations served as a model-informed precision dosing approach and suggested that different optimal dose regimens in various scenarios should be considered rather than flat dosing. The evaluation of vancomycin exposure-efficacy relationship indicated that lower target level of AUC0-24/MIC may be needed to achieve clinical effectiveness in children, which was used to derive the recommended dosing regimen. Further prospective studies will be needed to corroborate and elucidate these results.
Collapse
Affiliation(s)
- Xianhuan Shen
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Xuejuan Li
- Shenzhen Children's HospitalShenzhenChina
| | - Jieluan Lu
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Jiahao Zhu
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Yaodong He
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Zhou Zhang
- Shenzhen Children's HospitalShenzhenChina
| | - Zebin Chen
- Shenzhen Children's HospitalShenzhenChina
| | | | - Xiaomei Fan
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Wenzhou Li
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
| |
Collapse
|
2
|
Fataar A, Pillay-Fuentes Lorente V, Decloedt EH, van Eck A, Reddy K, Dramowski A, Bekker A. A Retrospective Study Evaluating Neonatal Vancomycin Loading Doses to Achieve a Therapeutic Target. Ther Drug Monit 2024:00007691-990000000-00238. [PMID: 38858809 DOI: 10.1097/ftd.0000000000001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/14/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Vancomycin is a glycopeptide antibiotic that has been used to treat hospital-acquired gram-positive infections for more than 5 decades. However, the literature is divided regarding the therapeutic advantages of vancomycin loading doses in neonates. OBJECTIVES This study aimed to investigate the effect of vancomycin loading doses on therapeutic target attainment in neonates with sepsis. METHODS A retrospective cohort study was conducted to compare the vancomycin target attainment (area under the curve 0-24 hours/minimum inhibitory concentration ≥400) in neonates before and after the 2019 change in vancomycin prescription guidelines at a neonatal unit in Cape Town, South Africa. As the standard of care, Bayesian modelling software was used to compute the area under the curve from the trough concentrations. RESULTS Two hundred ten neonates were included. Multivariate regression analysis showed a 2-fold increase in the odds of target attainment among neonates receiving a loading dose of vancomycin. Early target attainment (within 8-12 hours of treatment initiation) was significantly higher in the loading dose group compared with the no loading dose group [97/105 (92.4%) versus 64/105 (61.0%); P < 0.001]. However, the overall proportion of neonates achieving target attainment at 24 hours was similar between groups [73/105 (69.5%) in the loading dose group versus 62/105 (59.0%) in the no loading dose group; P = 0.110]. The nephrotoxicity rates were low [2/105 (1.9%) in the loading dose group and 2/105 (1.9%) in the no loading dose group]. CONCLUSIONS The addition of a vancomycin loading dose to neonates may facilitate early therapeutic target attainment.
Collapse
Affiliation(s)
- Aaqilah Fataar
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Veshni Pillay-Fuentes Lorente
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and
| | - Eric H Decloedt
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; and
| | - Andrew van Eck
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kessendri Reddy
- Division of Medical Microbiology, Department of Pathology, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
3
|
King MA, Cross SJ, Morton TH, Hijano DR, Greene WL, Sun Y, Tang L, Pauley JL, Bourque MS, Christensen AM. Evaluation of Continuous Infusion Vancomycin in a Pediatric Hematology/Oncology Population. Pediatr Infect Dis J 2024; 43:520-524. [PMID: 38359358 PMCID: PMC11098708 DOI: 10.1097/inf.0000000000004278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND Continuous infusion vancomycin (CIV) may benefit children who are unable to achieve therapeutic concentrations with intermittent vancomycin dosing and may facilitate outpatient administration by alleviating the burden of frequent dosing intervals. Previous studies have used variable dosing regimens and steady-state concentration goals. The purpose of this study was to evaluate the total daily dose (TDD) of CIV required to achieve therapeutic steady-state concentrations of 15-25 µg/mL in pediatric hematology/oncology patients. METHODS A single-center retrospective study was performed for patients treated with CIV from January 2017 to June 2019. The primary outcome was the TDD required to achieve therapeutic steady-state concentrations on CIV. Secondary outcomes included time to reach therapeutic steady-state concentrations, CIV indications and adverse events associated with CIV. RESULTS Data were collected for 71 courses of CIV in 60 patients. Median patient age was 4 years (range: 0.4-20 years). The median TDD required to achieve initial therapeutic concentrations was 50.3 mg/kg/d (interquartile range: 38.8-59.2) and was further divided into age-based cohorts. TDD in mg/kg was significantly lower in the older cohort ( P < 0.001), but there was no statistically significant difference between age-based cohorts with TDD in mg/m 2 ( P = 0.97). Median time to achieve first therapeutic concentration was 19.3 hours (range: 8.6-72.3 hours). The most common indication for CIV was ease of outpatient administration (69.0%). Acute kidney injury incidence was minimal (4.2%). CONCLUSIONS CIV is associated with rapid attainment of target concentrations in pediatric hematology/oncology patients and is safe and well tolerated.
Collapse
Affiliation(s)
- Madeleine A. King
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children’s Research Hospital, Memphis, TN
| | - Shane J. Cross
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN
| | - Theodore H. Morton
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
| | - Diego R. Hijano
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN
| | - William L. Greene
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children’s Research Hospital, Memphis, TN
| | - Yilun Sun
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Li Tang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jennifer L. Pauley
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN
| | - Melissa S. Bourque
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children’s Research Hospital, Memphis, TN
| | - Anthony M. Christensen
- Department of Pharmacy and Pharmaceutical Services, St. Jude Children’s Research Hospital, Memphis, TN
| |
Collapse
|
4
|
Kanazawa N, Shigemi A, Amadatsu N, Arimura K, Shimono S, Oda K, Chuang VTG, Matsumoto K, Kawamura H, Terazono H. A cohort study of the risk factors and the target AUC to avoid vancomycin-associated acute kidney injury in pediatric patients. J Infect Chemother 2024; 30:323-328. [PMID: 37940038 DOI: 10.1016/j.jiac.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In recent years, Vancomycin (VCM) dosing design using area under the concentration-time curve (AUC) has been recommended as a measure of efficacy and safety, but there are fewer reports on pediatric patients than on adults. In this study, we evaluated the threshold of AUC for AKI occurrence in pediatric patients and investigated the factors that contribute to the occurrence of AKI. METHODS Pediatric patients aged 1-15 years on VCM treatment who underwent TDM at Kagoshima University Hospital from April 2016 to March 2022 were included in the computation of AUC using pediatric population pharmacokinetic parameters. RESULTS The ROC curve showed that the AUC threshold for the risk of developing AKI was 583.0 μg・h/mL, and the AUC-ROC curve was 0.873 (sensitivity 0.930, specificity 0.750). Univariate analysis showed that factors associated with AKI incidence were the duration of VCM administration, ICU admission, and AUCSS. Concomitant medications identified as risk factors for AKI incidence were tazobactam/piperacillin, liposomal amphotericin B, calcineurin inhibitors, contrast agents, and H2-receptor blockers. The multivariate analysis showed that AUC ≧ 583.0 μg・h/mL (odds ratio 20.14, 95% CI 3.52-115.22, p < 0.001) and H2-receptor blockers (odds ratio 8.70, 95% confidence interval = 1.38-54.87, p = 0.02) were independent factors for AKI incidence. CONCLUSIONS We showed that in pediatric patients receiving VCM, the risk of AKI increases as AUC increases. The findings imply that concurrent use of VCM and H2-receptor blockers may increase the risk of AKI.
Collapse
Affiliation(s)
- Naoko Kanazawa
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Akari Shigemi
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan; Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Nao Amadatsu
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kotaro Arimura
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Shohei Shimono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan
| | - Victor Tuan Giam Chuang
- Discipline of Pharmacy, Curtin Medical School, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Hideki Kawamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Hideyuki Terazono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan.
| |
Collapse
|
5
|
Brandon HH, Burgess DS, Wallace KL, Autry EB, Olney KB. Vancomycin AUC 0-24 estimation using first-order pharmacokinetic methods in pediatric patients. Pharmacotherapy 2024; 44:294-300. [PMID: 38533999 DOI: 10.1002/phar.2916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION The optimal dosing and monitoring of vancomycin in pediatrics is still unknown but has evolved to emphasize area under the curve over 24 h (AUC0-24) over minimum concentration (Cmin) monitoring. Real-world data supporting the feasibility of two-concentration kinetics with first-order equations for the estimation of vancomycin AUC0-24 in pediatric patients are lacking. OBJECTIVES To describe the interplay of vancomycin dose, AUC0-24, and Cmin using first-order equations within four pediatric age groups. METHODS This is a single-center, retrospective cohort study analyzing pediatric patients (<18 years) receiving intravenous vancomycin between 2020 and 2022. Included patients received at least 24 h of intravenous vancomycin with two concentrations obtained within 96 h of therapy initiation. Patients with baseline renal dysfunction were excluded. Patients were divided into four age categories: neonates (≤28 days), infants (29 days to <1 year), children (1-12 years), and adolescents (13-17 years). First-order equations were utilized to estimate pharmacokinetic parameters and AUC0-24. RESULTS Overall, 219 patients (median age of 6 years [IQR 1-12]) met inclusion criteria. The median vancomycin daily dose was 30 mg/kg in neonates, 70 mg/kg in infants and children, and 52 mg/kg in adolescents. Median Cmin and AUC0-24 values among all age groups were 8.68 mg/L and 505 mg * h/L, respectively. For AUC0-24 values outside of the therapeutic range (400-600 mg * h/L), more values were SUPRAtherapeutic (>600 mg * h/L) than SUBtherapeutic (<400 mg * h/L). The overall trend within our data showed suboptimal correlation between Cmin and AUC0-24. However, 71% of patients with Cmin values of 5-10 mg/L had an AUC0-24 within the therapeutic range of 400-600 mg * h/L, whereas 23 patients (92%) with a SUPRAtherapeutic AUC0-24 had a Cmin value ≥15 mg/L. Approximately 10% of patients experienced acute kidney injury. CONCLUSIONS Our data describe the relationship between vancomycin dose, Cmin, and AUC0-24 in pediatric patients. We demonstrated the feasibility of using first-order equations to estimate AUC0-24, using two concentrations obtained at steady state to monitor efficacy and safety in pediatric patients receiving intravenous vancomycin. Our data showed suboptimal correlation between AUC0-24 and Cmin, which indicates that Cmin should not be used as a surrogate marker for a therapeutic AUC0-24 in pediatric patients. In alignment with the 2020 vancomycin consensus guidelines, we suggest utilizing AUC0-24 for efficacy and safety monitoring.
Collapse
Affiliation(s)
- Hope H Brandon
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - David S Burgess
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Katie L Wallace
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Elizabeth B Autry
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Katie B Olney
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| |
Collapse
|
6
|
Morales Junior R, Juodinis VD, de Souza DC, Santos SRCJ. Pharmacokinetics and therapeutic target attainment of vancomycin in pediatric post-liver transplant patients. Braz J Infect Dis 2023; 27:103688. [PMID: 37977199 PMCID: PMC10698562 DOI: 10.1016/j.bjid.2023.103688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/26/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Vancomycin is widely prescribed to treat or prevent Gram-positive infections in pediatric liver transplant recipients. The objective of this prospective cohort study is to describe vancomycin pharmacokinetics and to evaluate the therapeutic target attainment after initial dose regimen. MATERIALS AND METHODS Patients with previous renal injury were excluded. Vancomycin therapy started with 40‒60 mg/kg/day. The pharmacokinetic parameters were assessed using two steady-state blood samples and the first-order kinetic equations. Therapeutic target was defined as vancomycin 24-hour Area Under the Curve/Minimum Inhibitory Concentration (AUC/MIC) ≥ 400 and < 600. RESULTS Sixteen patients were included. The found vancomycin clearance, half-life, and volume of distribution were, respectively: 2.1 (1.3‒2.8) mL/kg/min, 3.3 (2.7‒4.4) hours, and 0.7 (0.5‒0.9) L/kg. With the initial dose, only 6 (37 %) patients reached the therapeutic target against Gram-positive pathogens with MIC 1 mg/L. After individual dose adjustments, all patients reached the target. The correlation between trough levels and AUC was low (R2 = 0.5). CONCLUSIONS Pediatric patients with preserved renal function after liver transplantation have an increased volume of distribution for vancomycin, and most patients present subtherapeutic levels after the standard initial dosing regimen. With the vancomycin AUC-guided monitoring and dosing, it is possible to improve therapeutic target attainment.
Collapse
Affiliation(s)
- Ronaldo Morales Junior
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas, Centro de Farmacocinética Clínica, São Paulo, SP, Brazil; Hospital Sírio-libanês, Unidade Pediátrica, São Paulo, SP, Brazil.
| | | | | | | |
Collapse
|
7
|
Wang F, Zhou M, Wang W, Zhu Z, Yan Y. Age-associated augmented renal clearance and low BMI trigger suboptimal vancomycin trough concentrations in children with haematologic diseases: data of 1453 paediatric patients from 2017 to 2022. BMC Pediatr 2023; 23:528. [PMID: 37880633 PMCID: PMC10601245 DOI: 10.1186/s12887-023-04288-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/05/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND It is usually difficult for the trough concentration of vancomycin to reach the recommended lower limit of 10 mg/L per the label dose in the paediatric population. Moreover, children with haematologic diseases who suffer from neutropenia are more likely to have lower exposure of vancomycin, and the risk factors have been poorly explored. METHOD We reviewed and analysed the initial trough concentration of vancomycin and synchronous cytometry and biochemical parameters in the blood of 1453 paediatric patients with haematologic diseases over a 6 year period, from 2017 to 2022. RESULTS Forty-five percent of the enrolled children had vancomycin trough concentrations below 5 mg/L after receiving a dose of 40 mg/kg/day, and the multiple regression showed that age (OR = 0.881, 95% CI 0.855 to 0.909, P < 0.001), BMI (OR = 0.941, 95% CI 0.904 to 0.980, P = 0.003) and the glomerular filtration rate (OR = 1.006, 95% CI 1.004 to 1.008, P < 0.001) were independent risk factors. A total of 79.7% of the children experienced augmented renal clearance, which was closely correlated to age-associated levels of serum creatinine. The vancomycin trough concentration was higher in children with aplastic anaemia than in those with other haematologic diseases due to a higher BMI and a lower glomerular filtration rate. CONCLUSION Age-associated augmented renal clearance and low BMI values contributed to suboptimal trough concentrations of vancomycin in children with haematologic diseases, and the effects of long-term use of cyclosporine and glucocorticoids need to be taken into account.
Collapse
Affiliation(s)
- Fengjiao Wang
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China
| | - Mi Zhou
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China
| | - Wenjuan Wang
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China
| | - Zengyan Zhu
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China.
| | - Yinghui Yan
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China.
| |
Collapse
|
8
|
Lim WXS, Seah XFV, Thoon KC, Han Z. Comparison of Vancomycin Trough-Based and 24-Hour Area Under the Curve Over Minimum Inhibitory Concentration (AUC/MIC)-Based Therapeutic Drug Monitoring in Pediatric Patients. J Pediatr Pharmacol Ther 2023; 28:430-438. [PMID: 38130493 PMCID: PMC10731924 DOI: 10.5863/1551-6776-28.5.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 10/07/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Vancomycin 24-hour area under the curve over minimum inhibitory concentration (AUC/MIC) monitoring has been recommended over trough-based monitoring in pediatric patients. This study compared the proportion of target attainment between vancomycin AUC/MIC and trough-based methods, and identified risk factors for subtherapeutic initial extrapolated targets. METHODS This was a retrospective, observational study conducted at KK Women's and Children's Hospital (KKH), Singapore. Patients aged 1 month to 18 years with stable renal function who received intravenous vancomycin between January 2014 and October 2017, with at least 2 vancomycin serum concentrations obtained after the first dose of vancomycin, were included. Using a pharmacokinetic software, namely Adult and Pediatric Kinetics (APK), initial extrapolated steady-state troughs and 24-hour AUC were determined by using a one-compartmental model. Statistical tests included Wilcoxon rank sum test, McNemar test, logistic regression, and classification and regression tree (CART) analysis. RESULTS Of the 82 pediatric patients included, a significantly larger proportion of patients achieved therapeutic targets when the AUC/MIC-based method (24, 29.3%) was used than with the trough-based method (9, 11.0%; p < 0.01). Patients with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 or with age <13 years had an increased risk of obtaining subtherapeutic targets. However, empiric vancomycin doses of 60 mg/kg/day would be sufficient to achieve serum therapeutic targets, using the AUC/MIC-based method. CONCLUSION The AUC/MIC-based vancomycin monitoring may be preferred because a larger proportion of patients could achieve initial therapeutic targets. Future prospective studies with larger sample size will be required to determine the optimal vancomycin strategy for pediatric patients.
Collapse
Affiliation(s)
- Wan Xuan Selina Lim
- Department of Pharmacy (WXSL, XFVS), KK Women's and Children's Hospital, Singhealth, Singapore
| | - Xue Fen Valerie Seah
- Department of Pharmacy (WXSL, XFVS), KK Women's and Children's Hospital, Singhealth, Singapore
| | - Koh Cheng Thoon
- Department of Infectious Diseases (KCT), Pediatrics, KK Women's and Children's Hospital, Singhealth, Singapore
| | - Zhe Han
- Department of Pharmacy (ZH), National University of Singapore, Singapore
| |
Collapse
|
9
|
Frymoyer A, Schwenk HT, Brockmeyer JM, Bio L. Impact of model-informed precision dosing on achievement of vancomycin exposure targets in pediatric patients with cystic fibrosis. Pharmacotherapy 2023; 43:1007-1014. [PMID: 37401162 DOI: 10.1002/phar.2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Vancomycin is commonly used to treat acute pulmonary exacerbations in pediatric patients with cystic fibrosis (CF) and a history of methicillin-resistant Staphylococcus aureus. Optimizing vancomycin exposure during therapy is essential and area under-the-curve (AUC)-guided dosing is now recommended. Model-informed precision dosing (MIPD) utilizing Bayesian forecasting is a powerful approach that can support AUC-guided dose individualization. The objective of the current study was to examine the impact of implementing an AUC-guided dose individualization approach supported via a MIPD clinical decision support (CDS) tool on vancomycin exposure, target attainment rate, and safety in pediatric patients with CF treated with vancomycin during clinical care. METHODS A retrospective chart review was performed in patients with CF at a single children's hospital comparing pre- and post-implementation of a MIPD approach for vancomycin supported by a cloud-based, CDS tool integrated into the electronic health record (EHR). In the pre-MIPD period, vancomycin starting doses of 60 mg/kg/day (<13 years) or 45 mg/kg/day (≥13 years) were used. Dose adjustment was guided by therapeutic drug monitoring (TDM) with a target trough 10-20 mg/L. In the post-MIPD period, starting dose and dose adjustment were based on the MIPD CDS tool predictions with a target 24 h AUC (AUC24 ) 400-600 mg*h/L. Exposure and target achievement rates were retrospectively calculated and compared. Rates of acute kidney injury (AKI) were also compared. RESULTS Overall, 23 patient courses were included in the pre-MIPD period and 21 patient courses in the post-MIPD period. In the post-MIPD period, an individualized MIPD starting dose resulted in 71% of patients achieving target AUC24 compared to 39% in the pre-MIPD period (p < 0.05). After the first TDM and dose adjustment, target AUC24 achievement was also higher post-MIPD versus pre-MIPD (86% vs. 57%; p < 0.05). AKI rates were low and similar between periods (pre-MIPD 8.7% vs. post-MIPD 9.5%; p = 0.9). CONCLUSION An MIPD approach implemented within a cloud-based, EHR-integrated CDS tool safely supported vancomycin AUC-guided dosing and resulted in high rates of target achievement.
Collapse
Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Hayden T Schwenk
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Jake M Brockmeyer
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Laura Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| |
Collapse
|
10
|
Nuryani N, Pambudi Utomo T, Wiyono N, Sutomo AD, Ling S. Cuffless Hypertension Detection using Swarm Support Vector Machine Utilizing Photoplethysmogram and Electrocardiogram. J Biomed Phys Eng 2023; 13:477-488. [PMID: 37868942 PMCID: PMC10589690 DOI: 10.31661/jbpe.v0i0.2206-1504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/11/2023] [Indexed: 10/24/2023]
Abstract
Background Hypertension is associated with severe complications, and its detection is important to provide early information about a hypertension event, which is essential to prevent further complications. Objective This study aimed to investigate a strategy for hypertension detection without a cuff using parameters of bioelectric signals, i.e., Electrocardiogram (ECG), Photoplethysmogram (PPG,) and an algorithm of Swarm-based Support Vector Machine (SSVM). Material and Methods This experimental study was conducted to develop a hypertension detection system. ECG and PPG bioelectrical records were collected from the Medical Information Mart for Intensive Care (MIMIC) from normal and hypertension participants and processed to find the parameters, used for the inputs of SSVM and comprised Pulse Arrival Time (PAT) and the characteristics of PPG signal derivatives. The SSVM was n Support Vector Machine (SVM) algorithm optimized using particle swarm optimization with Quantum Delta-potential-well (QDPSO). The SSVMs with different inputs were investigated to find the optimal detection performance. Results The proposed strategy was performed at 96% in terms of F1-score, accuracy, sensitivity, and specificity with better performance than the other methods tested and methods and also could develop a cuff-free hypertension monitoring system. Conclusion Hypertension using SSVM, ECG, and PPG parameters is acceptably performed. The hypertension detection had lower performance utilizing only PPG than both ECG and PPG.
Collapse
Affiliation(s)
- Nuryani Nuryani
- Department of Physics, University of Sebelas Maret Jl. Ir. Sutami 36A Kentingan Jebres Surakarta 57126, Indonesia
| | - Trio Pambudi Utomo
- Department of Physics, University of Sebelas Maret Jl. Ir. Sutami 36A Kentingan Jebres Surakarta 57126, Indonesia
| | - Nanang Wiyono
- Faculty of Medicine, University of Sebelas Maret Jl. Ir. Sutami 36A Kentingan Jebres Surakarta 57126, Indonesia
| | - Artono Dwijo Sutomo
- Department of Physics, Graduate Program, University of Sebelas Maret Jl. Ir. Sutami 36A Kentingan Jebres Surakarta 57126, Indonesia
| | - Steve Ling
- Centre for Health Technologies, University of Technology Sydney, Broadway NSW 2007, Australia
| |
Collapse
|
11
|
Rao Z, Guo SM, Wei YM. Individualized Delivery of Vancomycin by Model-Informed Bayesian Dosing Approach to Maintain an AUC24 Target in Critically Ill Patients. Chemotherapy 2023; 69:49-55. [PMID: 37591210 DOI: 10.1159/000531638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 06/12/2023] [Indexed: 08/19/2023]
Abstract
INTRODUCTION Monitoring of AUC24 was updated recommendation in the guideline for the therapeutic drug monitoring (TDM) of vancomycin in Chinese pharmacological society published in 2020. Vancomycin pharmacokinetic profiles are diverse and unique in critically ill patients because of the drastic variability of the patients' physiological parameters, while the study for population pharmacokinetic (PPK) models in Chinese critically ill patients has been rarely reported. The objectives of this study were to construct a PPK model to describe the pharmacokinetic characteristics of vancomycin in critically ill patients and to individualize vancomycin dosing by model-informed Bayesian estimation for maintenance of AUC24 target at 400-650 mg h/L recommended by the 2020 guideline. METHODS Vancomycin with different dosing was administered intravenously over 1 h for critically ill patients, TDM was started at 48 h or 72 h since initiation of vancomycin therapy for patients. Blood samples were collected from patients for trough concentrations or Cmax. Vancomycin concentrations were determined by high-performance liquid chromatography method with ultraviolet detection. PPK model was performed using the nonlinear mixed-effect model (NONMEM®). Individual PK parameters for critically ill patients treated with vancomycin were estimated using a post hoc empirical Bayesian method based on the final PPK model. AUC24 was calculated as the total daily dose divided by the clearance (L/h). RESULTS The PPK of vancomycin was determined by a one-compartment model with creatinine clearance as fixed effects. The PK estimates in the final model generally agreed with the median estimates and were contained within the 95% CI generated from the bootstrap results, indicating good precision and stability in the final model. The visual predictive check plots showed the adequate predictive performance of the final PK model and supported a good model fit. The model-informed Bayesian estimation was used to predict the AUC24 of critically ill patient by the acquired TDM results, and the dosing adjustment by maintenance of AUC24 at 400-650 mg h/L had made a great therapeutic effect for the case. CONCLUSION This study established a PPK model of vancomycin in Chinese critically ill patients, and individualized dosing of vancomycin by model-informed Bayesian estimation to maintain an AUC24 target at 400-650 mg h/L has been successfully applied in clinic. This result supports the continued use of model-informed Bayesian estimation to vancomycin treatment in critically ill patients.
Collapse
Affiliation(s)
- Zhi Rao
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China,
- Department of Pharmacy, The First Hospital of Lanzhou University, Lanzhou, China,
| | - Si-Ming Guo
- School of Pharmacy, Lanzhou University, Lanzhou, China
| | - Yan-Ming Wei
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China
| |
Collapse
|
12
|
Salehpour N, Riley LD, Gonzales MJ, Kobic E, Nix DE. Performance of Bayesian Area Under the Concentration-Time Curve-Based Pharmacokinetic Dosing Based on a One-Compartment Model and Trough-Only Monitoring for Vancomycin. Antimicrob Agents Chemother 2023; 67:e0017223. [PMID: 37133362 PMCID: PMC10269041 DOI: 10.1128/aac.00172-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023] Open
Abstract
A novel Bayesian method was developed to interpret serum vancomycin concentrations (SVCs) following the administration of one or more vancomycin doses with potential varying doses and intervals based on superposition principles. The method was evaluated using retrospective data from 442 subjects from three hospitals. The patients were required to receive vancomycin for more than 3 days, have stable renal function (fluctuation in serum creatinine of ≤0.3 mg/dL), and have at least 2 trough concentrations reported. Pharmacokinetic parameters were predicted using the first SVC, and the fitted parameters were then used to predict subsequent SVCs. Using only covariate-adjusted population prior estimates, the first two SVC prediction errors were 47.3 to 54.7% for the scaled mean absolute error (sMAE) and 62.1 to 67.8% for the scaled root mean squared error (sRMSE). "Scaled" refers to the division of the MAE or RMSE by the mean value. The Bayesian method had minimal errors for the first SVC (by design), and for the second SVC, the sMAE was 8.95%, and the sRMSE was 36.5%. The predictive performance of the Bayesian method did degrade with subsequent SVCs, which we attributed to time-dependent pharmacokinetics. The 24-h area under the concentration-time curve (AUC) was determined from simulated concentrations before and after the first SVC was reported. Prior to the first SVC, 170 (38.4%) patients had a 24-h AUC of <400 mg · h/L, 186 (42.1%) had a 24-h AUC within the target range, and 86 (19.5%) had a 24-h AUC of >600 mg · h/L. After the first SVC was reported, 322 (72.9%) had a 24-h AUC within the target range, 68 (15.4%) had low values, and 52 (11.8%) had high values based on the model simulation. Target attainments were 38% before the first SVC and 73% after the first SVC. The hospitals had no policies or procedures in place for targeting 24-h AUCs, although the trough target was typically 13 to 17 mg/L. Our data provide evidence of time-dependent pharmacokinetics, which will require regular therapeutic drug monitoring regardless of the method used to interpret SVCs.
Collapse
Affiliation(s)
- Niloufar Salehpour
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | - Lacey D. Riley
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
- Banner University Medical Center—Phoenix, Phoenix, Arizona, USA
| | - Marcos J. Gonzales
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
| | - Emir Kobic
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
- Banner University Medical Center—Phoenix, Phoenix, Arizona, USA
| | - David E. Nix
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona, USA
- Banner University Medical Center—Tucson, Tucson, Arizona, USA
| |
Collapse
|
13
|
Mitchell B, Kormelink L, Kuhn R, Schadler A, Autry E. Retrospective review of vancomycin monitoring via trough only versus two-point estimated area under the curve in pediatric and adult patients with cystic fibrosis. Pediatr Pulmonol 2023; 58:239-245. [PMID: 36203329 DOI: 10.1002/ppul.26190] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The primary objective of this study was to compare the occurrence of acute kidney injury (AKI) in patients with cystic fibrosis (CF) receiving intravenous (IV) vancomycin monitored through single serum trough concentrations and two-point estimated area under the curve (AUC). Time to next exacerbation and return to baseline lung function were also assessed. METHODS A retrospective review was conducted in patients of all ages with CF admitted to the University of Kentucky who received IV vancomycin between October 2015 and January 2021. Patients were excluded if they received less than 5 days of IV vancomycin therapy. RESULTS A total of 113 adults and 42 pediatric encounters met the inclusion criteria. There was no statistically significant difference in occurrence of AKI, however, all grade 2-3 AKIs were in the serum through the monitoring group. Adult patients monitored with AUC also had a higher return to baseline lung function over trough monitoring (86% vs. 57%) (p = 0.002). There was not a statistically significant difference in time to the next exacerbation in either group. CONCLUSIONS Adult patients with CF experienced less severe AKIs when monitored with AUC versus trough. The results of this study indicate that AUC monitoring may enhance the efficacy of IV vancomycin in adult patients with CF.
Collapse
Affiliation(s)
- Billie Mitchell
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, Kentucky, USA.,Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Lauren Kormelink
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, Kentucky, USA.,Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Robert Kuhn
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, Kentucky, USA.,Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Aric Schadler
- Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA.,Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Elizabeth Autry
- Department of Pharmacy, University of Kentucky Healthcare, Lexington, Kentucky, USA.,Department of Pharmacy, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA.,Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| |
Collapse
|
14
|
Elrggal ME, Haseeb A, AlGethamy M, Ahsan U, Saleem Z, Althaqafi AS, Alshuail SS, Alsiddiqi ZA, Iqbal MS, Alzahrani AF, AlQarni A, Radwan RM, Qul AKS, Mahrous AJ, Alsharif JM, Alqurashi MK, Faidah HS, Aldurdunji M. Dose optimization of vancomycin in obese patients: A systematic review. Front Pharmacol 2023; 14:965284. [PMID: 37033643 PMCID: PMC10081578 DOI: 10.3389/fphar.2023.965284] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background: Dose optimization of vancomycin plays a substantial role in drug pharmacokinetics because of the increased incidence of obesity worldwide. This systematic review was aimed to highlight the current dosing strategy of vancomycin among obese patients. Methods: This systematic review was in concordance with Preferred Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The literature search was carried out on various databases such as Scopus, PubMed/MEDLINE, ScienceDirect and EMBASE using Keywords and MeSH terms related to vancomycin dosing among obese patients. Google Scholar was also searched for additional articles. The English language articles published after January, 2000 were included in this study. The quality of the study was assessed using different assessment tools for cohort, and case reports. Results: A total of 1,029 records were identified. After screening, 18 studies were included for the final review. Of total, twelve studies are retrospective and remaining six are case-control studies. A total of eight studies were conducted in pediatrics while remaining studies were conducted in adult population. Most of the studies reported the dosing interval every 6-8 h. Differences in target trough concentration exist with respect to target ranges. The administration of loading dose (20-25 mg/kg) followed by maintenance dose (15-25 mg/kg) of vancomycin is recommended in adult patients to target therapeutic outcomes. Moreover, a dose of 40-60 mg/kg/day appears appropriate for pediatric patients. Conclusion: The initial dosing of vancomycin based on TBW could be better predictor of vancomycin trough concentration. However, the clinical significance is uncertain. Therefore, more studies are needed to evaluate the dosing strategy of vancomycin in overweight or obese patients.
Collapse
Affiliation(s)
- Mahmoud E. Elrggal
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdul Haseeb
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
- *Correspondence: Abdul Haseeb,
| | - Manal AlGethamy
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Umar Ahsan
- Department of Infection Prevention and Control Program, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Areej Sultan Althaqafi
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Sattam Saad Alshuail
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Zohair Ahmad Alsiddiqi
- Department of Internal Medicine, Alnoor Specialist Hospital Makkah, Makkah, Saudi Arabia
| | - Muhammad Shahid Iqbal
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Albaraa Faraj Alzahrani
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Abdullmoin AlQarni
- Alnoor Specialist Hospital Makkah, Department of Infectious Diseases, Makkah, Saudi Arabia
| | - Rozan Mohammad Radwan
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ameer Khalid Saab Qul
- Pharmaceutical Care Department, Alnoor Specialist Hospital Makkah, Department of Infection Prevention and Control Program, Makkah, Saudi Arabia
| | - Ahmad Jamal Mahrous
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Jumana Majdi Alsharif
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| | | | - Hani Saleh Faidah
- Department of Microbiology, Faculty of Medicine, Umm AL-Qura University, Makkah, Saudi Arabia
| | - Mohammed Aldurdunji
- Department of Clinical Pharmacy, College of Pharmacy, Umm AL-Qura University, Makkah, Saudi Arabia
| |
Collapse
|
15
|
Alsultan A, Al Munjem MF, Atiq KM, Aljehani ZK, Al Muqati H, Almohaizeie A, Ballal DA, Refaei TM, Al Jeraisy M, Assiri A, Abouelkheir M. Population pharmacokinetics of vancomycin in very low birth weight neonates. Front Pediatr 2023; 11:1093171. [PMID: 37063687 PMCID: PMC10101232 DOI: 10.3389/fped.2023.1093171] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 03/03/2023] [Indexed: 04/18/2023] Open
Abstract
Introduction Vancomycin dosing in very low birth weight (VLBW) neonates is challenging. Compared with the general neonatal population, VLBW neonates are less likely to achieve the vancomycin therapeutic targets. Current dosing recommendations are based on studies of the general neonatal population, as only a very limited number of studies have evaluated vancomycin pharmacokinetics in VLBW neonates. The main aim of this study was to develop a vancomycin population pharmacokinetic model to optimize vancomycin dosing in VLBW neonates. Methods This multicenter study was conducted at six major hospitals in Saudi Arabia. The study included VLBW neonates who received vancomycin and had at least one vancomycin serum trough concentration measurement at a steady state. We developed a pharmacokinetic model and performed Monte Carlo simulations to develop an optimized dosing regimen for VLBW infants. We evaluated two different targets: AUC0-24 of 400-600 or 400-800 µg. h/mL. We also estimated the probability of trough concentrations >15 and 20 µg/mL. Results In total, we included 236 neonates, 162 in the training dataset, and 74 in the validation dataset. A one-compartment model was used, and the distribution volume was significantly associated only with weight, whereas clearance was significantly associated with weight, postmenstrual age (PMA), and serum creatinine (Scr). Discussion We developed dosing regimens for VLBW neonates, considering the probability of achieving vancomycin therapeutic targets, as well as different toxicity thresholds. The dosing regimens were classified according to PMA and Scr. These dosing regimens can be used to optimize the initial dose of vancomycin in VLBW neonates.
Collapse
Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Correspondence: Abdullah Alsultan Manal Abouelkheir
| | | | | | - Zekra Kamel Aljehani
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Hessa Al Muqati
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almohaizeie
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Dalia Ahmed Ballal
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Tahani Makki Refaei
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Majed Al Jeraisy
- Pharmacy Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulmohsen Assiri
- Pharmaceutical Care Administration, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Manal Abouelkheir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Misr International University, Cairo, Egypt
- Correspondence: Abdullah Alsultan Manal Abouelkheir
| |
Collapse
|
16
|
Aljutayli A, Thirion DJ, Nekka F. Critical assessment of the revised guidelines for vancomycin therapeutic drug monitoring. Biomed Pharmacother 2022; 155:113777. [DOI: 10.1016/j.biopha.2022.113777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/02/2022] Open
|
17
|
RUIZ J, GARCÍA-ROBLES A, MARQUÉS MR, COMPANY MJ, SOLANA A, POVEDA JL. Influence of pharmacokinetic/pharmacodynamic ratio on vancomycin treatment response in pediatric patients with Staphylococcus aureus bacteremia. Minerva Pediatr (Torino) 2022; 74:525-529. [DOI: 10.23736/s2724-5276.18.04978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
18
|
Alakeel YS, Alanazi GA, Alawbathani BS, Alshutwi KI, Alahmed YS. Vancomycin dosing required to achieve a therapeutic level in children post-surgical correction of congenital heart disease. Medicine (Baltimore) 2022; 101:e30145. [PMID: 36254077 PMCID: PMC9575798 DOI: 10.1097/md.0000000000030145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The vancomycin dosing range for safe and effective treatment remains uncertain for children who had corrective surgery for a congenital heart disease (CHD). We aimed to determine the vancomycin dosing requirements for this subgroup of patients. This prospective cohort study included children younger than 14 years old with CHD who received intravenous vancomycin for at least 3 days at the Pediatric Cardiology section of King Abdulaziz Medical City, Riyadh. In total, 140 pediatric patients with CHD were included with a median age of 0.57 years (interquartile range 0.21-2.2). The mean vancomycin total daily dose (TDD), 37.71 ± 6.8 mg/kg/day, was required to achieve a therapeutic trough concentration of 7-20 mg/L. The patient's age group and the care setting were significant predictors of the vancomycin dosing needs. Neonates required significantly lower doses of 34 ± 6.03 mg/kg/day (P = .002), and young children higher doses of 43.97 ± 9.4 mg/kg/day (P = .003). The dosage requirements were independent of the type of cardiac lesion, cardiopulmonary surgery exposure, sex, and BMI percentile. However, the patients in the pediatric cardiac ward required higher doses of vancomycin 41.08 ± 7.06 mg/kg/day (P = .039). After the treatment, 11 (8.5%) patients had an elevated Scr, and 3 (2.3%) patients developed AKI; however, none of the patients' sociodemographic factors or clinical variables, or vancomycin therapy characteristics was significantly associated with the renal dysfunction. Overall, the vancomycin TDD requirements are lower in pediatric post-cardiac surgery compared to non-cardiac patients and are modulated by several factors.
Collapse
Affiliation(s)
- Yousif S. Alakeel
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
- * Correspondence: Yousif S. Alakeel, PharmD, MPH, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (e-mail: )
| | - Ghadah A. Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Bushra S. Alawbathani
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Kadi I. Alshutwi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yazeed S. Alahmed
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Department of Pediatrics, College of Medicine, Qassim University, Qassim, Saudi Arabia
- Division of Pediatric Cardiology, Cardiac Sciences, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| |
Collapse
|
19
|
Hussain K, Salat MS, Rauf S, Rathi M, Khan M, Naz F, Khan WA, Ikram R, Ambreen G. Practical approaches to improve vancomycin-related patient outcomes in pediatrics- an alternative strategy when AUC/MIC is not feasible. BMC Pharmacol Toxicol 2022; 23:64. [PMID: 35987842 PMCID: PMC9392299 DOI: 10.1186/s40360-022-00606-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 08/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background Anecdotal experience and studies have shown that most pediatric patients fail to reach target therapeutic vancomycin trough levels (VTLs) and required higher total daily doses (TDD). This retrospective study aims to evaluate the frequency of hospitalized children who achieved target VTLs with a vancomycin (VNCO) dosing regimen of 40-60 mg/kg/d q6h and to assess the VNCO-TDD required to attain the target and their effects on clinical outcomes in pediatric patients. Methods After ethical approval, patients of 3 month-12 years were evaluated in this chart review study who received ≥ 3 intravenous-VNCO doses and appropriately drawn blood samples of VTLs between October 2019 to June 2020. Data were retrieved for demographic and clinical characteristics, culture reports, VNCO-regimen, subsequent steady-state VTLs, concomitant nephrotoxic medications, and serum creatinine. Clinical pharmacists made interventions in VNCO therapy and higher VNCO-TDD were used. Safety of higher vs standard daily doses and their clinical impact on duration of therapy, hospital stay, and survival were evaluated. Results A total of 89 (39.1%) patients achieved target VTLs (SD-group). The smallest proportion (18.2%) of 2–6 years patients achieved target VTLs and reported the lowest mean value of 10.1 ± 0.2 mg/L which was a significant difference (p < 0.05) from all subgroups. Subtherapeutic VTLs were observed in 139 (60.9%) cases (HD-group), who received higher VNCO-TDD of 72 ± 8.9 mg/kg/d q6h to achieve the targets. Duration of therapy in culture-proven septic patients was significantly (p = 0.025) longer in SD-group [18.4 ± 12.2 days] than HD-group [15.1 ± 8.9 days]. Nephrotoxicity and electrolyte imbalance were comparable in groups. Length of hospital stay was significantly (p = 0.011) longer [median 22 (range 8–55) days] in SD-group compared to HD-group [median 16 (range 8–37) days]. Number of patients survived in HD-group were significantly (p = 0.008) higher than SD-group [129 (92.8%) vs 75 (84.3%)]. Conclusion Initial Vancomycin doses of 72 ± 8.9 mg/kg/day q6h are required to achieve therapeutic target in 3 months to 12 years patients. High doses are not associated with higher nephrotoxicity than reported with low doses. In addition, efficient pharmacist intervention for the use of higher VNCO-TDD may improve clinical outcomes in terms of duration of therapy, hospital stay, and survival.
Collapse
|
20
|
Amano E, Tanaka R, Ono H, Tatsuta R, Hashimoto T, Hiramatsu K, Itoh H. Association of Vancomycin Trough Concentration and Clearance With Febrile Neutropenia in Pediatric Patients. Ther Drug Monit 2022; 44:543-551. [PMID: 35821590 DOI: 10.1097/ftd.0000000000000978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Febrile neutropenia promotes renal drug excretion. Adult and pediatric patients with febrile neutropenia exhibit a lower vancomycin concentration/dose (relative to bodyweight) ratio than those with other infections. In pediatric patients, renal function relative to bodyweight varies depending on age, and vancomycin clearance is age dependent. This study aimed to analyze the effects of febrile neutropenia on the pharmacokinetics of vancomycin in age-stratified pediatric patients. METHODS This retrospective, single-center, observational cohort study analyzed 112 hospitalized pediatric patients who met the selection criteria and intravenously received vancomycin at the Department of Pediatrics of the Oita University Hospital between April 2011 and October 2019. RESULTS The febrile neutropenia (n = 46) cohort exhibited a significantly higher estimated glomerular filtration rate than the nonfebrile neutropenia (n = 66) cohort. Compared with those in the nonfebrile neutropenia cohort, the daily vancomycin dose relative to bodyweight and vancomycin clearance were significantly higher, and the vancomycin trough concentration and vancomycin concentration/dose ratio were significantly lower in the febrile neutropenia cohort. In the age groups of 1-6 and 7-12 years, compared with those in the nonfebrile neutropenia cohort, the vancomycin concentration/dose ratio was significantly lower, and vancomycin clearance was significantly higher in the febrile neutropenia cohort. Univariate and multivariate analyses identified febrile neutropenia as the independent factor influencing vancomycin concentration/dose ratio and clearance only in pediatric patients aged 1-6 years. CONCLUSIONS Increased initial dosage and therapeutic drug monitoring-guided dose optimization are critical for the therapeutic efficacy of vancomycin in pediatric patients with febrile neutropenia, especially in those aged 1-6 years.
Collapse
Affiliation(s)
- Erino Amano
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Hiroyuki Ono
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Ryosuke Tatsuta
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Takehiro Hashimoto
- Department of Respiratory Medicine and Infectious Diseases, Oita University, Faculty of Medicine, Yufu, Oita, Japan
| | - Kazufumi Hiramatsu
- Department of Respiratory Medicine and Infectious Diseases, Oita University, Faculty of Medicine, Yufu, Oita, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| |
Collapse
|
21
|
Wysocki E, Tansmore J. When There Is No Trough: Use and Outcomes of Continuous-Infusion Vancomycin at a Free-Standing Children's Hospital. J Pediatr Pharmacol Ther 2022; 27:452-456. [DOI: 10.5863/1551-6776-27.5.452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 11/07/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
There is minimal published literature regarding the use of continuous-infusion vancomycin (CIV) in children. The objective of this study was to describe the use, dosing requirements, and outcomes of CIV at a free-standing children's hospital.
METHODS
This is a retrospective review of patients who received CIV while admitted to Nationwide Children's Hospital between July 1, 2010, and June 30, 2020. The total daily dose (TDD) of vancomycin required to attain a target serum vancomycin concentration (SVC) was compared between CIV and intermittent-infusion vancomycin (IIV) administration regimens. Safety outcomes and treatment failure were also explored.
RESULTS
Fourteen patients (77% male) with a median age of 7 years (IQR = 1, 10 years) were included. Most patients (71%) were started on CIV in anticipation of outpatient parenteral antimicrobial therapy. The median TDD required to achieve a target SVC was higher with IIV compared with CIV (82.4 mg/kg/day vs 50.5 mg/kg/day; p = 0.02). Despite higher TDD with IIV, median SVC with IIV was similar to SVC with CIV (16.6 mg/L vs 17.6 mg/L; p = 2.00). There were no safety concerns or therapeutic failures identified with CIV.
CONCLUSIONS
Continuous-infusion vancomycin was a well-tolerated and effective alternative to IIV for the patients included in this study. The TDD of vancomycin required to achieve a target SVC was lower in patients receiving CIV compared with those receiving IIV.
Collapse
Affiliation(s)
- Emma Wysocki
- Enterprise Pharmacy (EW), Geisinger Medical Center, Danville, PA
| | - Jessica Tansmore
- Department of Pharmacy (JT), Nationwide Children's Hospital, Columbus, OH
| |
Collapse
|
22
|
Chuphan C, Sukarnjanaset W, Puthanakit T, Wattanavijitkul T. Population Pharmacokinetics and Pharmacodynamics of Vancomycin in Pediatric Patients With Various Degrees of Renal Function. J Pediatr Pharmacol Ther 2022; 27:419-427. [DOI: 10.5863/1551-6776-27.5.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Although vancomycin dosage recommendations in the pediatric setting for methicillin-resistant Staphylococcus aureus (MRSA) infection indicate that ≥60 mg/kg/day is correlated to a desired area under the vancomycin concentration time curve from 0 to 24 hours to minimum inhibitory concentration ratio (AUC0–24 hr/MIC) ≥400, for some patients this dosage is inadequate or relates to toxicity. This study purposed to explore vancomycin dosing for pediatrics with various degrees of renal function.
METHODS
Routine monitoring data were retrospectively collected from patients, aged 1 month to 18 years. Population pharmacokinetic analysis was performed by using non-linear mixed-effect model with NONMEM software, and Monte Carlo simulation was conducted by using Crystal Ball software.
RESULTS
Two hundred twelve patients with 348 vancomycin serum concentrations were included. Median age was 3.5 years (IQR, 0.9–10.9), median weight was 14.0 kg (IQR, 7.2–30.4), with baseline estimated glomerular filtration rate (eGFR) ranging from 15.5 to 359.3 mL/min/1.73 m2. A 1-compartment model with first-order elimination sufficiently described vancomycin PK. The dosing targeting AUC0–24hr/MIC ≥400 and AUC0–24hr <800 mg•h/L for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2 was 12.5, 25, 40, 60, and 70 mg/kg/day, respectively. All vancomycin dosing obtained >85% of the cumulative fraction of response across the MIC distribution of MRSA.
CONCLUSIONS
Vancomycin dosing of 12.5, 25, 40, 60, and 70 mg/kg/day is suggested for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2, respectively.
Collapse
Affiliation(s)
- Chanika Chuphan
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanyawee Puthanakit
- Department of Pediatrics (TP), Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thitima Wattanavijitkul
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
23
|
Han J, Sauberan J, Tran MT, Adler-Shohet FC, Michalik DE, Tien TH, Tran L, DO DH, Bradley JS, Le J. Implementation of Vancomycin Therapeutic Monitoring Guidelines: Focus on Bayesian Estimation Tools in Neonatal and Pediatric Patients. Ther Drug Monit 2022; 44:241-252. [PMID: 34145165 DOI: 10.1097/ftd.0000000000000910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The 2020 consensus guidelines for vancomycin therapeutic monitoring recommend using Bayesian estimation targeting the ratio of the area under the curve over 24 hours to minimum inhibitory concentration as an optimal approach to individualize therapy in pediatric patients. To support institutional guideline implementation in children, the objective of this study was to comprehensively assess and compare published population-based pharmacokinetic (PK) vancomycin models and available Bayesian estimation tools, specific to neonatal and pediatric patients. METHODS PubMed and Embase databases were searched from January 1994 to December 2020 for studies in which a vancomycin population PK model was developed to determine clearance and volume of distribution in neonatal and pediatric populations. Available Bayesian software programs were identified and assessed from published articles, software program websites, and direct communication with the software company. In the present review, 14 neonatal and 20 pediatric models were included. Six programs (Adult and Pediatric Kinetics, BestDose, DoseMeRx, InsightRx, MwPharm++, and PrecisePK) were evaluated. RESULTS Among neonatal models, Frymoyer et al and Capparelli et al used the largest PK samples to generate their models, which were externally validated. Among the pediatric models, Le et al used the largest sample size, with multiple external validations. Of the Bayesian programs, DoseMeRx, InsightRx, and PrecisePK used clinically validated neonatal and pediatric models. CONCLUSIONS To optimize vancomycin use in neonatal and pediatric patients, clinicians should focus on selecting a model that best fits their patient population and use Bayesian estimation tools for therapeutic area under the -curve-targeted dosing and monitoring.
Collapse
Affiliation(s)
- Jihye Han
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | - Jason Sauberan
- Neonatal Research Institute, SHARP Mary Birch Hospital for Women and Newborns, San Diego
| | | | | | - David E Michalik
- MemorialCare Miller Children's and Women's Hospital Long Beach, Long Beach, California
| | | | - Lan Tran
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | | | - John S Bradley
- Division of Infectious Diseases, University of California at San Diego, Louisiana Jolla; and
- Rady Children's Hospital-San Diego, San Diego, California
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| |
Collapse
|
24
|
Huang G, Qiu Y, Liu T, Lu J. Comparison of vancomycin clearance between augmented renal clearance and normal renal function in critically ill infants: A population pharmacokinetics study. J Clin Pharmacol 2022; 62:863-872. [PMID: 35049078 DOI: 10.1002/jcph.2029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 01/16/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Guang‐Ming Huang
- Department of Pharmacy The First Affiliated Hospital of Guangxi Medical University Nanning Guangxi Province People's Republic of China
| | - Yue Qiu
- Department of Pharmacy The First Affiliated Hospital of Guangxi Medical University Nanning Guangxi Province People's Republic of China
| | - Tao‐Tao Liu
- Department of Pharmacy The First Affiliated Hospital of Guangxi Medical University Nanning Guangxi Province People's Republic of China
| | - Jie‐Jiu Lu
- Department of Pharmacy The First Affiliated Hospital of Guangxi Medical University Nanning Guangxi Province People's Republic of China
| |
Collapse
|
25
|
Silveira ALO, Alves GCDS, Xie J, Roberts JA, Sanches C. Vancomycin population pharmacokinetic modeling in children using Bayesian estimation and a Non Parametric Approach. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902020000x2e19313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - Jiao Xie
- The University of Queensland, Australia
| | - Jason A Roberts
- The University of Queensland, Australia; Royal Brisbane and Women’s Hospital, Australia; Royal Brisbane and Women’s Hospital, Australia; The University of Queensland, Australia
| | | |
Collapse
|
26
|
Tuan HM, Anh NT, Quan KT, Thang NV, Huy VQ. Effect of Initial Vancomycin Dose and Creatinine Clearance on the Attainment of Target Trough Concentration in Children. Curr Pediatr Rev 2022; 18:318-325. [PMID: 35255798 DOI: 10.2174/1573396318666220307115307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/20/2021] [Accepted: 01/12/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Vancomycin is a glycopeptide antibiotic that is used to treat serious grampositive infections. However, therapeutic drug monitoring for vancomycin is not performed routinely in Vietnam in clinical practices. Monitoring of serum vancomycin concentration or trough levels is necessary to ensure the efficacy and safety of vancomycin therapy. OBJECTIVE This study aims to determine the impact of initial vancomycin dose and creatinine clearance on target trough attainment in hospitalized Vietnamese children. METHODS A prospective study with patients who received vancomycin for at least three days was conducted. Subsequently, demographic data, clinical diagnosis, vancomycin dosage, and serum creatinine levels were recorded. The vancomycin trough level was collected and creatinine clearance and adjusted vancomycin doses were calculated. RESULTS A total of 40 eligible patients were enrolled. Patients' mean age, body weight, and height were 1.4 years old, 9.8 kg, and 75.5 cm, respectively. The mean vancomycin dose was 55.83 ± 19.34 mg/kg/day. The mean creatinine clearance was 80.18 ± 29.14 ml/min. The median trough level was 11.09 (7.84 - 16.46) μg/ml. There was no significant difference in the mean initial and the adjusted vancomycin doses (p = 0.062). However, there were statistically significant differences of initial (p = 0.004) or adjusted doses (p = 0.016) between groups of creatinine clearance. The trough vancomycin concentration was not statistically significant (p = 0.406) between these groups. CONCLUSION Target trough vancomycin level may be associated with creatinine clearance but did not proportionally correspond to the vancomycin dose. Therefore, monitoring vancomycin trough levels is necessary to achieve the target trough and to ensure vancomycin efficacy and safety in treating severely infected Vietnamese children.
Collapse
Affiliation(s)
- Ha Manh Tuan
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Tuan Anh
- Molecular Biomedical Center, University Medical Center, Ho Chi Minh City, Vietnam
| | - Kim Tran Quan
- American International Hospital, Thu Duc City, Vietnam
| | | | - Vu Quang Huy
- University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| |
Collapse
|
27
|
Resztak M, Sobiak J, Czyrski A. Recent Advances in Therapeutic Drug Monitoring of Voriconazole, Mycophenolic Acid, and Vancomycin: A Literature Review of Pediatric Studies. Pharmaceutics 2021; 13:1991. [PMID: 34959272 PMCID: PMC8707246 DOI: 10.3390/pharmaceutics13121991] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 01/05/2023] Open
Abstract
The review includes studies dated 2011-2021 presenting the newest information on voriconazole (VCZ), mycophenolic acid (MPA), and vancomycin (VAN) therapeutic drug monitoring (TDM) in children. The need of TDM in pediatric patients has been emphasized by providing the information on the differences in the drugs pharmacokinetics. TDM of VCZ should be mandatory for all pediatric patients with invasive fungal infections (IFIs). Wide inter- and intrapatient variability in VCZ pharmacokinetics cause achieving and maintaining therapeutic concentration during therapy challenging in this population. Demonstrated studies showed, in most cases, VCZ plasma concentrations to be subtherapeutic, despite the updated dosages recommendations. Only repeated TDM can predict drug exposure and individualizing dosing in antifungal therapy in children. In children treated with mycophenolate mofetil (MMF), similarly as in adult patients, the role of TDM for MMF active form, MPA, has not been well established and is undergoing continued debate. Studies on the MPA TDM have been carried out in children after renal transplantation, other organ transplantation such as heart, liver, or intestine, in children after hematopoietic stem cell transplantation or cord blood transplantation, and in children with lupus, nephrotic syndrome, Henoch-Schönlein purpura, and other autoimmune diseases. MPA TDM is based on the area under the concentration-time curve; however, the proposed values differ according to the treatment indication, and other approaches such as pharmacodynamic and pharmacogenetic biomarkers have been proposed. VAN is a bactericidal agent that requires TDM to prevent an acute kidney disease. The particular group of patients is the pediatric one. For this group, the general recommendations of the dosing may not be valid due to the change of the elimination rate and volume of distribution between the subjects. The other factor is the variability among patients that concerns the free fraction of the drug. It may be caused by both the patients' population and sample preconditioning. Although VCZ, MMF, and VAN have been applied in pediatric patients for many years, there are still few issues to be solve regarding TDM of these drugs to ensure safe and effective treatment. Except for pharmacokinetic approach, pharmacodynamics and pharmacogenetics have been more often proposed for TDM.
Collapse
Affiliation(s)
- Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (J.S.); (A.C.)
| | | | | |
Collapse
|
28
|
Oskarsdottir K, Haraldsson A, Thorkelsson T, Oskarsdottir T, Gunnarsson P, Thors V. Children may need higher vancomycin doses to achieve therapeutic levels. Acta Paediatr 2021; 110:3077-3082. [PMID: 34233034 DOI: 10.1111/apa.16025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 11/30/2022]
Abstract
AIM Vancomycin is frequently used in paediatric hospitals. Data suggest trough levels of 10-20 mg/L are needed to achieve bacterial killing. This study aimed to evaluate if commonly used dosing regimens are efficient in reaching these levels and if therapeutic drug monitoring (TDM) was appropriately used. METHODS All children receiving intravenous vancomycin at the Children´s Hospital Iceland between 2012 and 2016 were included. Vancomycin trough levels were registered. Student t test, Wilcoxon test and regression models were used for statistical analysis. RESULTS A total of 105 children received 163 vancomycin treatments (55/105 neonates). Average daily dose in neonates was 23.4 mg/kg/day and 38.4 mg/kg/day for older children. No TDM was done in 58 treatments (35.6%). First trough levels were <10mg/L in 52.4% and <15mg/L in 92% of cases. Therapeutic levels were less likely achieved in children with malignancy (11.8%) compared with others (36.8%, p = 0.09). CONCLUSIONS In more than half of the cases, trough drug levels were <10 mg/L and malignancy was associated with the lowest probability of reaching therapeutic levels. This study suggests that starting doses of vancomycin in children should be higher, especially in relation to malignant diseases and supports the importance of antibiotic stewardship to ensure optimal antibiotic use.
Collapse
Affiliation(s)
| | - Asgeir Haraldsson
- Faculty of Medicine University of Iceland Reykjavik Iceland
- Children's Hospital IcelandLandspitali University Hospital Reykjavik Iceland
| | - Thordur Thorkelsson
- Faculty of Medicine University of Iceland Reykjavik Iceland
- Children's Hospital IcelandLandspitali University Hospital Reykjavik Iceland
| | | | - Petur Gunnarsson
- Pharmacy department Landspitali University Hospital Reykjavik Iceland
- Faculty of Pharmaceutical Sciences University of Iceland Reykjavik Iceland
| | - Valtyr Thors
- Faculty of Medicine University of Iceland Reykjavik Iceland
- Children's Hospital IcelandLandspitali University Hospital Reykjavik Iceland
| |
Collapse
|
29
|
Population Pharmacokinetics and Dosing Optimization of Vancomycin in Pediatric Liver Transplant Recipients. Microbiol Spectr 2021; 9:e0046021. [PMID: 34612690 PMCID: PMC8510181 DOI: 10.1128/spectrum.00460-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methicillin-resistant Staphylococcus aureus infections are a significant cause of morbidity and mortality in pediatric liver transplant (LT) recipients. Physiological changes following LT may affect vancomycin pharmacokinetics; however, appropriate dosing to achieve sufficient drug exposure (i.e., 24-h area under the concentration-time curve [AUC24]/MIC ≥ 400) in pediatric LT recipients has not been reported. This retrospective pharmacokinetics study of LT recipients aged <18 years utilized data on patient characteristics with vancomycin concentrations and dosing information obtained from electronic medical records. Population pharmacokinetics analysis was conducted by nonlinear mixed-effects modeling with the Phoenix NLME software. Potential covariates were screened with univariate and multivariate analysis. Monte Carlo simulations were performed using the final model to explore appropriate dosing. The study included 270 pharmacokinetics profiles encompassing 1,158 concentrations measured in 161 patients. The median age was 13.3 (interquartile range, 7.6 to 53.5) months, serum creatinine (sCr) was 0.16 (0.12 to 0.23) mg/dl, and days from LT (DFLT) was 17 (6 to 31). Multivariate analysis demonstrated that lower sCr and shorter DFLT were associated with higher clearance. By post hoc estimation, the average clearance and volume of distribution were 0.18 liters/h/kg and 1.01 liters/kg, respectively. The Monte Carlo simulations revealed that only 16% of patients achieved an AUC24/MIC of ≥400 with the assumed vancomycin MIC of 1 μg/ml. DFLT and sCr were significant covariates for vancomycin clearance in pediatric LT recipients. Standard vancomycin dosing may be insufficient, and higher or more frequent dosing may be required to achieve an AUC24/MIC of ≥400 in pediatric LT recipients with normal renal function. IMPORTANCE We evaluated vancomycin pharmacokinetics in pediatric LT recipients and developed a population pharmacokinetics model by considering various factors that might account for alterations in vancomycin pharmacokinetics. Our analyses revealed that lower serum creatinine levels and a shorter duration from the day of LT were associated with higher vancomycin clearance and led to subtherapeutic drug exposure. We also performed Monte Carlo simulations to determine the appropriate dosing strategy in pediatric LT recipients, which revealed that a standard vancomycin dosing might be insufficient and that higher or more frequent dosing might be necessary to achieve an AUC24/MIC of ≥400 in pediatric LT recipients with normal renal function. To the best of our knowledge, this is the first study to assess vancomycin pharmacokinetics in pediatric LT recipients by population pharmacokinetics analysis.
Collapse
|
30
|
Aljutayli A, El-Haffaf I, Marsot A, Nekka F. An Update on Population Pharmacokinetic Analyses of Vancomycin, Part II: In Pediatric Patients. Clin Pharmacokinet 2021; 61:47-70. [PMID: 34671937 DOI: 10.1007/s40262-021-01050-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 10/20/2022]
Abstract
Vancomycin is widely used in pediatric patients, however, large inter- and intraindividual variability are observed in vancomycin pharmacokinetics, affecting proper therapeutic monitoring. This review aimed at providing a comprehensive synthesis of the population pharmacokinetic models of vancomycin in pediatric patients and identifying potential factors responsible for the variability observed in various subpopulations. We conducted a literature search of the PubMed and EMBASE databases to obtain population pharmacokinetic studies for vancomycin published between January 2011 and January 2020, which resulted in a total of 33 studies. Vancomycin pharmacokinetics were generally characterized using a one-compartment model (n = 27), while a two-compartment model was used in six studies. The median (interquartile range) of the typical vancomycin clearance (CL) and the total volume of distribution adjusted to the median or mean body weight of the respective study was 0.103 L/h/kg (0.071-0.125) and 0.64 L/kg (0.59-1.03), respectively. Median weight-adjusted CL between different child age groups, such as infants and adolescents, did not appear to vary significantly, although the sample size for many age groups was very small. Examples of the conditions with relatively abnormal vancomycin pharmacokinetic values include renal insufficiency, sepsis, hematological and solid malignancy, and hypothermia treatment. Factors influencing pediatric vancomycin pharmacokinetics after adjusting for size and maturation include various renal function descriptors and some case-specific variables such as dialysate flow rate, ultrafiltrate output, and hypothermia. This review was able to document possible variables explaining the high variability observed in certain subpopulations and contrast vancomycin pharmacokinetics in different pediatric subpopulations.
Collapse
Affiliation(s)
- Abdullah Aljutayli
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de Pharmacométrie, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada. .,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada. .,Centre de recherche, CHU Sainte-Justine, 175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Fahima Nekka
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de Pharmacométrie, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada.,Centre de recherches mathématiques, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montreal, QC, Canada, H3T 1J4
| |
Collapse
|
31
|
Khare M, Haag MB, Kneese G, Austin JP, Perlman J, Azim A, Orsi C, Foster BA. A Multicenter Retrospective Study of Vancomycin Dosing by Weight Measures in Children. Hosp Pediatr 2021; 11:e289-e296. [PMID: 34645692 DOI: 10.1542/hpeds.2020-004465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Vancomycin carries risks of treatment failure and emergent resistance with underexposure and renal toxicity with overexposure. Children with overweight or obesity may have altered pharmacokinetics. We aimed to examine how body weight metrics influence vancomycin serum concentrations and to evaluate alternative dosing strategies. METHODS This was a multicenter retrospective cohort study across 3 large, academic hospitals. Patients aged 2 to 18 years old who received ≥3 doses of intravenous vancomycin were included. Weight metrics included total body weight, adjusted body weight, ideal body weight, body surface area, and allometric weight. Outcomes included vancomycin concentration and ratios of area under the curve (AUC) to minimum inhibitory concentration (MIC). Regression analyses were used to examine which body-weight identifier predicted outcomes. RESULTS Of the 1099 children, 45% were girls, mean age was 9.0 (SD = 5.4) years, 14% had overweight, and 17% had obesity. Seventy-five percent of children had vancomycin concentrations in the subtherapeutic range by trough <10 µg/mL, and 63% had a ratio of AUC to MIC <400 μg-hr/mL. Three percent had a supratherapeutic initial trough >20 µg/mL or ratio of AUC to MIC >600 μg-hr/mL. Serum vancomycin concentrations were higher in children with overweight or obesity compared with children who were at a normal weight or underweight; the mean ratio of AUC to MIC also trended higher in the groups with overweight or obesity. CONCLUSIONS Most children received vancomycin regimens that produced suboptimal trough levels. Children with overweight or obesity experienced higher vancomycin trough levels than children of normal weight despite receiving lower total body weight dosing. Using the ratio of AUC to MIC was a better measure of drug exposure.
Collapse
Affiliation(s)
- Manaswitha Khare
- Department of Pediatrics, School of Medicine, University of California, San Diego, San Diego, California
| | - Meredith B Haag
- Department of Pediatrics, Oregon Health and Science University and Doernbecher Children's Hospital, Portland, Oregon
| | - Garrett Kneese
- Department of Pediatrics, School of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Jared P Austin
- Department of Pediatrics, Oregon Health and Science University and Doernbecher Children's Hospital, Portland, Oregon
| | - Jeremy Perlman
- Department of Pediatrics, School of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Aniqa Azim
- Department of Pediatrics, Oregon Health and Science University and Doernbecher Children's Hospital, Portland, Oregon
| | - Carisse Orsi
- Department of Pediatrics, School of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Byron A Foster
- Department of Pediatrics, Oregon Health and Science University and Doernbecher Children's Hospital, Portland, Oregon
| |
Collapse
|
32
|
Bosley TE, Kuhn RJ, Gardner B, Autry EB, Fuller M, Overley CL. Optimization of Vancomycin Dosing to Achieve Target Area Under the Curve in Pediatrics. J Pediatr Pharmacol Ther 2021; 26:746-752. [PMID: 34588940 DOI: 10.5863/1551-6776-26.7.746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/20/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Vancomycin dosing requirements to achieve a target area under curve/minimum inhibitory concentration (AUC/MIC) of 400 to 600 mg•hr/L have not been established in pediatrics. Dose modeling studies and recent guidelines suggest dosing higher than historical recommendations. This study examines dosing requirements to achieve target AUC/MIC in human pediatric patients. METHODS This retrospective study includes 77 patients, aged 1 month to 18 years, at a single center, who received at least 2 days of intravenous vancomycin with a pharmacokinetic monitoring note and calculated AUC/MIC. Dosing to achieve target AUC/MIC was evaluated by age and indication. Nephrotoxicity was also assessed. RESULTS The mean dose required to achieve target AUC/MIC for all patients was 67.7 mg/kg/day. Adjusting for age, the mean dose required to achieve target AUC/MIC of 400 to 600 mg•hr/L was found to be statistically significantly different among 3 age cohorts: 1 month to 5 years, 6 to 12 years, and 13 to 18 years [F(2,74) = 15.32, p < 0.001], with mean requirements of 79 ± 14.1, 65.6 ± 21.1, and 53.9 ± 17.1 mg/kg/day, respectively. Dosing requirements were also found to be statistically significantly different across indications [F(6,70) = 4.84, p < 0.001]. Acute kidney injury was identified in 5 patients (6.5%). CONCLUSIONS The vancomycin dose required to achieve target AUC/MIC in pediatrics was significantly higher in younger pediatric patients and ranged from 53.9 to 79 mg/kg/day, confirming recent guideline recommendations. Doses can be further adjusted for indication. Nephrotoxicity rates remain low compared with historical rates with single trough monitoring.
Collapse
|
33
|
Al-Mazraawy BO, Girotto JE. Comparing Vancomycin Area Under the Curve With a Pharmacist Protocol that Incorporates Trough and Maximum Doses at a Children's Hospital. J Pediatr Pharmacol Ther 2021; 26:740-745. [PMID: 34588939 DOI: 10.5863/1551-6776-26.7.740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 01/21/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Updated vancomycin guidelines suggest dose adjustment based on area under the curve in a 24-hour period (AUC24). This study aims to determine whether a pharmacist managed vancomycin protocol that incorporates maximum dosing paired with trough monitoring can achieve appropriate vancomycin AUC24 exposures. METHODS A retrospective review was performed evaluating vancomycin usage from October 2018 through September 2019 at a children's hospital. Patients with less than 4 doses or lack a trough concentration were excluded. Vancomycin AUC24 were estimated using 2 calculations: 1) the Le method, incorporating age and serum creatinine, and 2) the trapezoidal method based upon population data and patient-specific trough. Target AUC24 ranges were assessed. AUC24 goals were 400 to 600 mg·hr/L, but due to known variations between calculations, a variance of 20 mg·hr/L was allowed for each end of the goal. Secondary analyses included evaluations of efficacy and toxicity. RESULTS Two-hundred twenty-three patients were included. Initial doses were estimated to meet AUC24 goals in only 63%. After trough-based dose modification, 81% achieved a therapeutic AUC24. Using the trapezoidal method, therapeutic concentrations were found in 51% of patients based on the initial dose and 77% after dose modification. Only 6.3% of patients had kidney injury with only 1 of those patients having any calculated AUC24 > 600 mg·hr/L and none above 620 mg·hr/L. No clinical failures were identified. CONCLUSIONS Increased initial dosing in infants and children is needed to result in AUC24 exposures recommended in the guidelines. Maximum dosing paired with trough monitoring may be an alternative to AUC24 monitoring in areas that are unable to perform AUC24 calculations. Prospective data are needed to validate these conclusions.
Collapse
|
34
|
Murphy ME, Tang Girdwood S, Goldman JL, Scheetz MH, Downes KJ. Precision dosing of vancomycin: in defence of AUC-guided therapy in children. J Antimicrob Chemother 2021; 76:2494-2497. [PMID: 34096598 PMCID: PMC8633448 DOI: 10.1093/jac/dkab194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In 2020, new vancomycin guidelines were released, recommending the transition from trough-based to AUC24 monitoring for adult and paediatric patients. Given the resources required to achieve this transition, there has been debate about the costs and benefits of AUC24-based monitoring. A recent narrative review of vancomycin therapeutic drug monitoring in paediatrics claims to have uncovered the methodological weaknesses of the data that informed the guidelines and advises against premature adoption of AUC24-guided monitoring. In this article, we present supporting arguments for AUC24-guided monitoring in children, which include that: (i) troughs alone are inadequate surrogates for AUC24; (ii) vancomycin-associated nephrotoxicity has significant consequences that warrant optimization of dosing; (iii) a substantial portion of children receiving vancomycin are at high risk for poor outcomes and deserve targeted monitoring; and (iv) limited efficacy data in support of AUC24 is not a justification to revert to a less supported monitoring approach.
Collapse
Affiliation(s)
- Mark E Murphy
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sonya Tang Girdwood
- Division of Clinical Pharmacology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jennifer L Goldman
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children’s Mercy Kansas City, Kansas City, MO, USA
- Division of Infectious Diseases, Children’s Mercy Kansas City, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri—Kansas City, Kansas City, MO, USA
| | - Marc H Scheetz
- Pharmacometrics Center of Excellence, Department of Pharmacy Practice, College of Pharmacy, Chicago, IL, USA
- Department of Pharmacology, College of Graduate Studies, Midwestern University, Chicago, IL, USA
- Department of Pharmacy, Northwestern Medicine, Chicago, IL, USA
| | - Kevin J Downes
- The Center for Clinical Pharmacology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- The Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
35
|
Zylbersztajn B, Parker S, Navea D, Izquierdo G, Ortiz P, Torres JP, Fajardo C, Diaz R, Valverde C, Roberts J. Population Pharmacokinetics of Vancomycin and Meropenem in Pediatric Extracorporeal Membrane Oxygenation Support. Front Pharmacol 2021; 12:709332. [PMID: 34483917 PMCID: PMC8411703 DOI: 10.3389/fphar.2021.709332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 08/04/2021] [Indexed: 12/27/2022] Open
Abstract
Objective: Describe primary pharmacokinetic/pharmacodynamic (PK/PD) parameters of vancomycin and meropenem in pediatric patients undergoing ECMO and analyze utilized dosing to reach PK/PD target. Design: Prospective, multicentric, population PK analysis. Setting: Two hospitals with pediatric intensive care unit. Patients: Pediatric patients (1 month - 15 years old) receiving vancomycin and meropenem for empiric or definitive infection treatment while ECMO support. Measurements and Main Results: Four serum concentration were obtained for patients receiving vancomycin (n = 9) and three for meropenem (n = 9). The PK/PD target for vancomycin was a ratio of the area under the curve to the minimal inhibitory concentration (AUC/MIC) of >400, and for meropenem was 4 times above MIC for 50% of the dosing interval (fT50% > 4xMIC). Pharmacokinetic modeling was performed using PMetrics 1.5.0. We included nine patients, with 11 PK profiles for each antimicrobial. The median age of patients was 4 years old (2 months - 13 years) and 45% were male. Creatinine clearance (CL) was 183 (30–550) ml/min/1.73 m2. The median dose was 13.6 (range 10–15) mg/kg every 6–12 h and 40 mg/kg every 8–12 h for vancomycin and meropenem, respectively. Two compartment models were fitted. Weight was included as a covariate on volume of the central compartment (Vc) for meropenem. Weight was included as a covariate on both Vc and clearance (CL) and serum creatinine was also included as a covariate on CL for vancomycin. The pharmacokinetic parameters CL and Vc were 0.139 ± 0.102 L/h/kg and 0.289 ± 0.295 L/kg for meropenem and 0.060 ± 0.055 L/h/kg and 0.419 ± 0.280 L/kg for vancomycin, respectively. Across each dosing interval 91% of patients achieved the PK/PD targets for adequate exposure for meropenem and 63.6% for vancomycin. Conclusion: Pharmacokinetic/pharmacodynamic objectives for vancomycin were achieved partially with conventional doses and higher dosing with extended infusion were needed in the case of meropenem.
Collapse
Affiliation(s)
| | - Suzanne Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | | | | | - Paula Ortiz
- Pediatric Intensive Care Unit, Roberto Del Rio Hospital, SantiagoChile
| | - Juan Pablo Torres
- Department of Infectious Disease, Clinica Las Condes, Santiago, Chile
| | | | - Rodrigo Diaz
- Intensive Care Unit, Clinica Las Condes, Santiago, Chile
| | | | - Jason Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.,Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, QLD, Australia
| |
Collapse
|
36
|
Population pharmacokinetics and dosing optimization of vancomycin in infants, children and adolescents with augmented renal clearance. Antimicrob Agents Chemother 2021; 65:e0089721. [PMID: 34339268 DOI: 10.1128/aac.00897-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Augmented renal clearance (ARC) can cause underexposure to vancomycin, thereby increasing the risk of treatment failure. Our objective was to evaluate population pharmacokinetics and optimize the dosing regimen of vancomycin in the pediatric population with ARC. Sparse pharmacokinetic sampling and therapeutic drug monitoring (TDM) data were collected from pediatric patients with ARC treated with vancomycin. A pharmacokinetic model was developed using NONMEM 7.2. The dosing regimen was optimized using Monte Carlo dose simulations. A total of 242 vancomycin serum concentrations from 113 patients (age range 0.4 to 14.9 years, 49 females and 64 males) were available. Mean vancomycin dose was 58.8 mg/kg/day (13.6 mg/kg/dose), and mean vancomycin serum trough concentration was 6.5 mg/L. A one-compartment pharmacokinetic model with first order elimination was developed. Body weight and age were the most significant and positive covariates for clearance and volume of distribution. To the pediatric population with ARC, the current recommended vancomycin dose of 60 mg/kg/day was associated with a high risk of underdosing. To reach the target AUC/MIC of 400-700 in these pediatric patients, the vancomycin dose should be increased to 75 mg/kg/day for infants and children between 1 month and 12 years of age, and 70 mg/kg/day for adolescents between 12 and 18 years of age. In conclusion, a one-compartment pharmacokinetic model with first-order elimination was established with body weight and age as significant covariates. An optimal dosing regimen was developed in pediatric patients with ARC aged 1 month -18 years.
Collapse
|
37
|
Alonso-Moreno M, Mejías-Trueba M, Herrera-Hidalgo L, Goycochea-Valdivia WA, Gil-Navarro MV. Efficacy and Safety of Continuous Infusion of Vancomycin in Children: A Systematic Review. Antibiotics (Basel) 2021; 10:antibiotics10080912. [PMID: 34438962 PMCID: PMC8388768 DOI: 10.3390/antibiotics10080912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022] Open
Abstract
Vancomycin is used to treat a wide variety of infections within the pediatric population. In adults, continuous infusion of vancomycin (CIV) has been evaluated as an alternative to intermittent infusion of vancomycin (IIV) with potential advantages. In children, the use of CIV is increasing; however, data is currently limited. The objective is to provide efficacy and safety evidence for CIV within this population. The review was carried out following PRISMA guidelines. A bibliographic search was performed for studies on PubMed and EMBASE. Clinical trials and observational studies that reported clinical efficacy and/or target attainment of CIV in pediatrics were included. Articles were reviewed to assess their design and target population, characteristics of vancomycin treatment and the main findings in terms of safety and efficacy. A total of 359 articles were identified, of which seven met the inclusion criteria. All of them evaluated the target attainment, six assessed safety but only three assessed clinical efficacy. The best administration method for this antibiotic within the pediatric population is still unknown due to limited evidence. However, studies conducted thus far suggest pharmacokinetic advantages for CIV. Further investigation is required, in particular for studies comparing IIV with CIV for clinical efficacy and toxicity outcomes.
Collapse
Affiliation(s)
- Marta Alonso-Moreno
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.A.-M.); (M.M.-T.)
| | - Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.A.-M.); (M.M.-T.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
- Correspondence: ; Tel.: +34-955-012-095
| | - Walter Alfredo Goycochea-Valdivia
- Unidad de Pediatría de Enfermedades Infecciosas, Reumatología e Inmunología, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
| | - María Victoria Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
| |
Collapse
|
38
|
Sridharan K, Abbasi MY, Mulubwa M. Population Pharmacokinetics and Dose Optimization of Vancomycin in Critically Ill Children. Eur J Drug Metab Pharmacokinet 2021; 46:539-546. [PMID: 34156647 DOI: 10.1007/s13318-021-00695-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Critically ill children may exhibit varied vancomycin pharmacokinetic parameters mainly due to altered protein binding, extracellular volume, and renal elimination. The objective of this study was to assess the pharmacokinetics of vancomycin in critically ill children and determine the optimum dose regimen. METHODS This was a cross-sectional study of critically ill children admitted to a pediatric intensive care unit. They received vancomycin dose of 15 mg/kg every 8 h for mild infections or every 6 h if infection was moderate or severe. A nonlinear mixed-effects modeling approach was applied in estimating pharmacokinetic parameters using Monolix 2019R2®. We performed Monte Carlo simulations to assess and optimize the dosing regimen using Simulx®. We used the ratio of the area under the concentration-time curve up to 24 h to minimum inhibitory concentration (AUC0-24/MIC) ≥ 400 as the pharmacokinetic-pharmacodynamic target. RESULTS Fifty-eight critically ill children with 145 concentrations were included in the present study. A one-compartment pharmacokinetic model with linear elimination described the concentration-time profile well. The estimated median (95% confidence intervals) volume of distribution (Vd) was 13.3 (10.8-16.5) l and clearance (CL) was 1.23 (1.03-1.45) l/h. Creatinine clearance significantly affected the CL of vancomycin. Monte Carlo simulations revealed that a dose of either 15 mg/kg 6 hourly or 20 mg/kg 8 hourly was likely to result into most critically ill children attaining the vancomycin lead pharmacokinetic-pharmacodynamic target. CONCLUSION We established pharmacokinetic parameters of vancomycin for critically ill children. We also observed that the current dosing regimen practiced in the intensive care unit was inadequate for achieving the pharmacokinetic-pharmacodynamic target. We recommend vancomycin dose escalation in critically ill pediatric patients from 15 mg/kg 8 hourly (current dosing regimen) to either 6 hourly or 20 mg/kg 8 hourly with intense therapeutic drug monitoring for adverse effects.
Collapse
Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
| | - Mohammad Yaseen Abbasi
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Mwila Mulubwa
- Drug Discovery and Development Centre (H3D), Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Observatory, 7925, South Africa
| |
Collapse
|
39
|
Shi L, Hatsukami DK, Koopmeiners JS, Le CT, Benowitz NL, Donny EC, Luo X. A mixed effects model for analyzing area under the curve of longitudinally measured biomarkers with missing data. Pharm Stat 2021; 20:1249-1264. [PMID: 34151513 DOI: 10.1002/pst.2146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/06/2021] [Accepted: 06/01/2021] [Indexed: 11/08/2022]
Abstract
A simple approach for analyzing longitudinally measured biomarkers is to calculate summary measures such as the area under the curve (AUC) for each individual and then compare the mean AUC between treatment groups using methods such as t test. This two-step approach is difficult to implement when there are missing data since the AUC cannot be directly calculated for individuals with missing measurements. Simple methods for dealing with missing data include the complete case analysis and imputation. A recent study showed that the estimated mean AUC difference between treatment groups based on the linear mixed model (LMM), rather than on individually calculated AUCs by simple imputation, has negligible bias under random missing assumptions and only small bias when missing is not at random. However, this model assumes the outcome to be normally distributed, which is often violated in biomarker data. In this paper, we propose to use a LMM on log-transformed biomarkers, based on which statistical inference for the ratio, rather than difference, of AUC between treatment groups is provided. The proposed method can not only handle the potential baseline imbalance in a randomized trail but also circumvent the estimation of the nuisance variance parameters in the log-normal model. The proposed model is applied to a recently completed large randomized trial studying the effect of nicotine reduction on biomarker exposure of smokers.
Collapse
Affiliation(s)
- Luoxi Shi
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dorothy K Hatsukami
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Psychiatry, Medical School, University of Minnesota, Minneapolis, Minnesota, USA
| | - Joseph S Koopmeiners
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chap T Le
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neal L Benowitz
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Eric C Donny
- Baptist Comprehensive Cancer Center and Department of Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Xianghua Luo
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA.,Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| |
Collapse
|
40
|
Hughes DM, Goswami S, Keizer RJ, Hughes MSA, Faldasz JD. Bayesian clinical decision support-guided versus clinician-guided vancomycin dosing in attainment of targeted pharmacokinetic parameters in a paediatric population. J Antimicrob Chemother 2021; 75:434-437. [PMID: 31670812 DOI: 10.1093/jac/dkz444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To compare a Bayesian clinical decision support (CDS) dose-optimizing software program with clinician judgement in individualizing vancomycin dosing regimens to achieve vancomycin pharmacokinetic (PK)/pharmacodynamic (PD) targets in a paediatric population. METHODS A retrospective review combined with a model-based simulation of vancomycin dosing was performed on children aged 1 year to 18 years at the University of California, San Francisco Benioff Children's Hospital Mission Bay. Dosing regimens recommended by the clinical pharmacists, 'clinician-guided', were compared with alternative 'CDS-guided' dosing regimens. The primary outcome was the percentage of occasions predicted to achieve steady-state trough levels within the target range of 10-15 mg/L, with a secondary outcome of predicted attainment of AUC24 ≥400 mg·h/L. Statistical comparison between approaches was performed using a standard t-test. RESULTS A total of n=144 patient occasions were included. CDS-guided regimens were predicted to achieve vancomycin steady-state troughs in the target range on 70.8% (102/144) of occasions, as compared with 37.5% (54/144) in the clinician-guided arm (P<0.0001). An AUC24 of ≥400 mg·h/L was achieved on 93% (112/121) of occasions in the CDS-guided arm versus 72% (87/121) of occasions in the clinician-guided arm (P<0.0001). CONCLUSIONS In a simulated analysis, the use of a Bayesian CDS tool was better than clinician judgement in recommending vancomycin dosing regimens in which PK/PD targets would be attained in children.
Collapse
Affiliation(s)
- David M Hughes
- Boston Medical Center, Boston, MA, USA.,University of California, San Francisco Medical Center, San Francisco, CA, USA
| | | | | | | | - Jonathan D Faldasz
- University of California, San Francisco Medical Center, San Francisco, CA, USA.,InsightRX, San Francisco, CA, USA
| |
Collapse
|
41
|
Kreitmeyr K, Pecar A, Mikolajczyk R, von Both U, Huebner J. Pediatric Antibiotic Stewardship: Optimization of Vancomycin Therapy Based on Individual Pharmacokinetics. Pediatr Infect Dis J 2021; 40:556-562. [PMID: 33956756 DOI: 10.1097/inf.0000000000003058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Vancomycin has been a first-line treatment for Gram-positive infections for decades. However, strategies for therapeutic drug monitoring (TDM) and dose-optimization in pediatrics remain controversial. In this study, we analyzed the impact of specific antibiotic stewardship interventions on efficacy and safety of vancomycin therapy. METHODS From September 2014 to May 2017, we conducted a prospective study to compare a control and a TDM intervention group in our tertiary care center. As part of an antibiotic stewardship program, we implemented internal guidelines on correct vancomycin dosing, TDM timing, as well as targeted trough level range and installed a pharmacokinetic (PK) consultation service to adapt vancomycin dosing to individually calculated PK parameters. As primary clinical outcomes, the percentage of patients with sustained therapeutic vancomycin trough levels and treatment days with therapeutic vancomycin trough levels, that is, 10-15 mg/L were analyzed. Secondary outcomes included nephrotoxicity, readmission rate and mortality. Median daily dose required to achieve therapeutic trough levels was examined. RESULTS Clinical outcomes for 90 control patients were compared with outcomes for 19 patients guided by a PK consultation service. Percentage of patients with sustained therapeutic vancomycin trough levels increased from 17.8% to 94.7% (P < 0.001) and percentage of treatment days with therapeutic vancomycin trough levels increased from 18.4% (117/637) to 665% (155/233, P < 0.001). Readmission rate decreased from 24.4% to 5.3% (P = 0.07). No differences in nephrotoxicity or mortality rate were observed between groups. A median daily dose of 72 mg/kg/d was required to achieve therapeutic trough levels. CONCLUSIONS Our data demonstrate that implementation of internal guidelines and a PK consultation service was associated with a profound improvement of vancomycin therapy and, therefore, patient safety.
Collapse
Affiliation(s)
- Katharina Kreitmeyr
- From the Division of Pediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Alenka Pecar
- From the Division of Pediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biostatistics and Informatics (IMEBI), Medical School of the Martin-Luther-University, Halle, Germany
- Epidemiological and Statistical Methods Research Group, Helmholtz-Center for Infection Research, Braunschweig, Germany
| | - Ulrich von Both
- From the Division of Pediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- Hospital Pharmacy, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Huebner
- From the Division of Pediatric Infectious Diseases, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Munich, Germany
- German Center for Infection Research (DZIF), Munich, Germany
| |
Collapse
|
42
|
Liang Y, Wu Z, Zhao L, Wu J, Chen X, Tang W, Zeng J. Therapeutic Drug Monitoring and Pharmacokinetic Analysis of Cyclosporine in a Pediatric Patient with Hemophagocytic Lymphohistiocytosis Complicated by Diabetes Insipidus: A Grand Round. Ther Drug Monit 2021; 43:303-306. [PMID: 33560100 DOI: 10.1097/ftd.0000000000000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease. Initial therapy is based on etoposide, dexamethasone, and cyclosporine (CSA). The pharmacokinetics (PKs) of CSA and other drugs are sometimes altered in patients with HLH complicated by diabetes insipidus (DI) but the precise mechanisms remain unknown. METHODS In this study, the authors present a case of a 4-year-old boy with HLH complicated by DI. CSA concentrations were determined by enzyme multiplied immunoassay technique; noncompartmental PK analysis of the plasma concentration-time data was performed using PKSolver; and linear regression analysis was performed to determine linearity of relationship between urine output and C0 levels of CSA. RESULTS Although C0 values of CSA were lower than the target levels, the patient was successfully treated and a good clinical outcome was achieved. Linear regression analysis showed a strong negative correlation between urine output and the serum trough concentration (C0) of CSA, pharmacokinetic analysis showed the main PK parameters of CSA as follows: C0, 50.2 mcg/L; peak concentration (Cmax), 723.4 mcg/L; area under the curve0-24, 7478.2 mcg·h/L; clearance, 0.77 L/h/kg, elimination half-life, 5.3 hours, and volume of distribution, 6.0 L/kg. CONCLUSIONS To the best of the authors' knowledge, this is the first report of the CSA PK profile in a patient with HLH complicated by DI. The authors suppose that a large fluid output and input leads to extensive CSA distribution. These results suggest that the monitoring of the Cmax and area under the curve of CSA might be more clinically and pharmacokinetically significant than that of C0 in patients with HLH complicated by DI. This case highlights the importance of therapeutic drug monitoring and demonstrates PK parameters of CSA in a pediatric patient with HLH complicated by DI.
Collapse
Affiliation(s)
- Yujian Liang
- Department of Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University; and
| | - Zhaoyi Wu
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Liyan Zhao
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jingjing Wu
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wen Tang
- Department of Pediatric Intensive Care Unit, The First Affiliated Hospital, Sun Yat-Sen University; and
| | - Jiawei Zeng
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
43
|
Avedissian SN, Le J, Neely MN, Cortés-Penfield N, Bradley J, Rybak MJ, Rhodes NJ. Comment on: AUCs and 123s: a critical appraisal of vancomycin therapeutic drug monitoring in paediatrics. J Antimicrob Chemother 2021; 76:2486-2488. [PMID: 34021756 DOI: 10.1093/jac/dkab145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Sean N Avedissian
- Antiviral Pharmacology Laboratory, University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE, USA.,University of Nebraska Medical Center, College of Pharmacy, Omaha, NE, USA
| | - Jennifer Le
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
| | - Michael N Neely
- University of Southern California, Keck School of Medicine, Division of Infectious Diseases, Los Angeles, CA, USA.,Laboratory of Applied Pharmacokinetics and Bioinformatics, The Saban Research Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | | | - John Bradley
- Division of Infectious Diseases, University of California San Diego School of Medicine and Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, USA.,School of Medicine, Wayne State University, Detroit, MI, USA.,Detroit Receiving Hospital, Detroit, MI, USA
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA.,Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA.,Northwestern Memorial Hospital, Chicago, IL, USA
| |
Collapse
|
44
|
Population Pharmacokinetic Models of Vancomycin in Paediatric Patients: A Systematic Review. Clin Pharmacokinet 2021; 60:985-1001. [PMID: 34002357 DOI: 10.1007/s40262-021-01027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Vancomycin is commonly used to treat gram-positive bacterial infections in the paediatric population, but dosing can be challenging. Population pharmacokinetic (popPK) modelling can improve individualization of dosing regimens. The primary objective of this study was to describe popPK models of vancomycin and factors that influence pharmacokinetic (PK) variability in paediatric patients. METHODS Systematic searches were conducted in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, International Pharmaceutical Abstracts and the grey literature without language or publication status restrictions from inception to 17 August 2020. Observational studies that described the development of popPK models of vancomycin in paediatric patients (< 18 years of age) were included. Risk of bias was assessed using the National Heart, Lung and Blood Institute Study Quality Assessment Tool for Case Series Studies. RESULTS Sixty-four observational studies (1 randomized controlled trial, 13 prospective studies and 50 retrospective studies of 9019 patients with at least 25,769 serum vancomycin concentrations) were included. The mean age was 2.5 years (range 1 day-18 years), serum creatinine was 47.1 ± 33.6 µmol/L, and estimated creatinine clearance was 97.4 ± 76 mL/min/1.73m2. Most studies found that vancomycin PK was best described by a one-compartment model (71.9%). There was a wide range of clearance and volume of distribution (Vd) values (range 0.014-0.27 L/kg/h and 0.43-1.46 L/kg, respectively) with interindividual variability as high as 49.7% for clearance and 136% for Vd, proportional residual variability up to 37.5% and additive residual variability up to 17.5 mg/L. The most significant covariates for clearance were weight, age, and serum creatinine or creatinine clearance, and weight for Vd. Variable dosing recommendations were suggested. CONCLUSION Numerous popPK models of vancomycin were derived, however external validation of suggested dosing regimens and analyses in subgroup paediatric populations such as dialysis patients are still needed before a popPK model with best predictive performance can be applied for dosing recommendations. Significant intraindividual and interindividual PK variability was present, which demonstrated the need for ongoing therapeutic drug monitoring and derivation of PK models for vancomycin for certain subgroup populations, such as dialysis patients.
Collapse
|
45
|
Maruyama H, Tanzawa A, Funaki T, Ito Y, Isayama T. Low vancomycin trough concentration in neonates and young infants. Pediatr Int 2021; 63:556-560. [PMID: 32894884 DOI: 10.1111/ped.14459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/23/2020] [Accepted: 08/31/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Vancomycin (VCM) is useful for treating methicillin-resistant Staphylococcus aureus. In infants, calibrating the initial VCM dose is difficult, and many regimens have been proposed. For instance, our center uses the VCM regimen recommended for infants in the 2012-13 Nelson's Pediatric Antimicrobial Therapy. Nonetheless, our experience has shown that the initial VCM trough concentrations were frequently off target. We therefore analyzed the data on the initial VCM trough concentration in infant patients at our center. METHODS The study subjects were inborn infants born between July 2014 and June 2019 who were given VCM at earlier than day 60 in the neonatal intensive care unit. The primary outcome was the initial VCM trough concentration. The patients were divided into three groups by VCM trough concentration: <10, 10-15, and >15 mg/L. We also estimated VCM trough concentration by one method using Monte Carlo simulation, based on Nelson regimen dosage. RESULTS Thirty-three patients were analyzed. The number of patients with <10, 10-15, and >15 mg/L was 24, 4, and 5, respectively. There was no significant difference in clinical characteristics between <10 versus 10-15 and 10-15 versus >15 mg/L. The numbers of patients with <10, 10-15, and >15 mg/L in the simulation were 26, 6, and 1, respectively. CONCLUSIONS Most initial VCM trough concentrations were below the target. We could not find any significant clinical characteristics, which affected VCM trough concentration. Increasing the VCM dosage of the Nelson regimen with simulation should therefore be considered.
Collapse
Affiliation(s)
- Hidehiko Maruyama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - Ayano Tanzawa
- Department of Pharmacy, National Center for Child Health and Development, Tokyo, Japan
| | - Takanori Funaki
- Division of Infectious Diseases, Department of Medical Subspecialties, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, Tokyo, Japan
| |
Collapse
|
46
|
Vancomycin dosing and therapeutic drug monitoring practices: guidelines versus real-life. Int J Clin Pharm 2021; 43:1394-1403. [PMID: 33913087 DOI: 10.1007/s11096-021-01266-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/05/2021] [Indexed: 02/07/2023]
Abstract
Background Correct dosing and therapeutic drug monitoring (TDM) practices are essential when aiming for optimal vancomycin treatment. Objective To assess target attainment after initial dosing and dose adjustments, and to determine compliance to dosing and TDM guidelines. Setting Tertiary care university hospital in Belgium. Method A chart review was performed in 150 patients, ranging from preterm infants to adults, treated intravenously with vancomycin. Patient characteristics, dosing and TDM data were compared to evidence-based hospital guidelines. Main outcome measures Target attainment of vancomycin after initial dosing and dose adjustments. Results Subtherapeutic concentrations were measured in 68% of adults, in 76% of children and in 52% of neonates after treatment initiation. Multiple dose adaptations (median 2, Q1 1-Q3 2) were required for target attainment, whilst more than 20% of children and neonates never reached targeted concentrations. Regarding compliance to the hospital guideline, some points of improvement were identified: omitted dose adjustment in adults with decreased renal function (53%), delayed sampling (16% in adults, 31% in children) and redundant sampling (34% of all samples in adults, 12% in children, 13% in neonates). Conclusion Target attainment for vancomycin with current dosing regimens and TDM is poor in all age groups. Besides, human factors should not be ignored when aiming for optimal treatment. This study reflects an ongoing challenge in clinical practice and highlights the need for optimization of vancomycin dosing strategies and improvement of awareness of all health care professionals involved.
Collapse
|
47
|
Avedissian SN, Rhodes NJ, Kim Y, Bradley J, Valdez JL, Le J. Augmented renal clearance of aminoglycosides using population-based pharmacokinetic modelling with Bayesian estimation in the paediatric ICU. J Antimicrob Chemother 2021; 75:162-169. [PMID: 31648297 DOI: 10.1093/jac/dkz408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/21/2019] [Accepted: 08/24/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate augmented renal clearance (ARC) using aminoglycoside clearance (CLAMINO24h) derived from pharmacokinetic (PK) modelling. METHODS A retrospective study at two paediatric hospitals of patients who received tobramycin or gentamicin from 1999 to 2016 was conducted. Compartmental PK models were constructed using the Pmetrics package, and Bayesian posteriors were used to estimate CLAMINO24h. ARC was defined as a CLAMINO24h of ≥130 mL/min/1.73 m2. Risk factors for ARC were identified using multivariate logistic regression. RESULTS The final population model was fitted to 275 aminoglycoside serum concentrations. Overall clearance (L/h) was=CL0×(TBW/70)0.75×AGEH/(TMH + AGEH) + CL1 (0.5/SCr), where TBW is total body weight, H is the Hill coefficient, TM is a maturation term and SCr is serum creatinine. Median CLAMINO24h in those with versus without ARC was 157.36 and 93.42 mL/min/1.73 m2, respectively (P<0.001). ARC was identified in 19.5% of 118 patients. For patients with ARC, median baseline SCr was lower than for those without ARC (0.38 versus 0.41 mg/dL, P=0.073). Risk factors for ARC included sepsis [adjusted OR (aOR) 3.77, 95% CI 1.01-14.07, P=0.048], increasing age (aOR 1.11, 95% CI 1-1.23, P=0.04) and low log-transformed SCr (aOR 0.16, 95% CI 0.05-0.52, P=0.002). Median 24 h AUC (AUC24h) was significantly lower in patients with ARC at 45.27 versus 56.95 mg·h/L, P<0.01. CONCLUSIONS ARC was observed in one of every five patients. Sepsis, increasing age and low SCr were associated with ARC. Increased clearance was associated with an attenuation of AUC24h in this population. Future studies are needed to define optimal dosing in paediatric patients with ARC.
Collapse
Affiliation(s)
- Sean N Avedissian
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA.,Midwestern University Chicago College of Pharmacy Center of Pharmacometric Excellence, Midwestern University, Downers Grove, IL, USA.,Antiviral Pharmacology Laboratory, University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE, USA.,University of Nebraska Medical Center, College of Pharmacy, Omaha, NE, USA
| | - Nathaniel J Rhodes
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA.,Midwestern University Chicago College of Pharmacy Center of Pharmacometric Excellence, Midwestern University, Downers Grove, IL, USA
| | - Yuna Kim
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
| | - John Bradley
- Division of Infectious Diseases, University of California San Diego School of Medicine and Rady Children's Hospital San Diego, CA, USA
| | - Joshua L Valdez
- Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - Jennifer Le
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA.,Miller Children's and Women's Hospital of Long Beach, Long Beach, CA, USA
| |
Collapse
|
48
|
Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C, Mueller BA, Pai MP, Wong-Beringer A, Rotschafer JC, Rodvold KA, Maples HD, Lomaestro BM. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2021; 77:835-864. [PMID: 32191793 DOI: 10.1093/ajhp/zxaa036] [Citation(s) in RCA: 584] [Impact Index Per Article: 194.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI, School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, CA
| | - Thomas P Lodise
- Albany College of Pharmacy and Health Sciences, Albany, NY, and Stratton VA Medical Center, Albany, NY
| | - Donald P Levine
- School of Medicine, Wayne State University, Detroit, MI, and Detroit Receiving Hospital, Detroit, MI
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA, and Rady Children's Hospital San Diego, San Diego, CA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | | | | | | | | | - Holly D Maples
- University of Arkansas for Medical Sciences College of Pharmacy & Arkansas Children's Hospital, Little Rock, AR
| | | |
Collapse
|
49
|
Yoo R, So H, Seo E, Kim M, Lee J. Impact of initial vancomycin pharmacokinetic/pharmacodynamic parameters on the clinical and microbiological outcomes of methicillin-resistant Staphylococcus aureus bacteremia in children. PLoS One 2021; 16:e0247714. [PMID: 33793589 PMCID: PMC8016336 DOI: 10.1371/journal.pone.0247714] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 02/11/2021] [Indexed: 01/02/2023] Open
Abstract
Optimal vancomycin exposure is important to minimize treatment failure of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. We aimed to analyze the impact of initial vancomycin pharmacokinetic/pharmacodynamic (PK/PD) parameters, including the initial vancomycin C trough and the area under the curve (AUC)/minimal inhibitory concentration (MIC) on the outcomes of pediatric MRSA bacteremia. The study population consisted of hospitalized children aged between 2 months and 18 years with MRSA bacteremia, in whom C trough was measured at least one time within the time period of January 2010 to March 2018. Demographic profiles, underlying diseases, and clinical/microbiological outcomes were abstracted retrospectively. During the study period, 73 cases of MRSA bacteremia occurred in children with a median age of 12.4 months. Severe clinical outcomes leading to intensive care unit stay and/or use of mechanical ventilation occurred in 47.5% (35/73); all-cause 30-day mortality was 9.7% (7/72). The median dosage of vancomycin was 40.0 mg/kg/day. There was a weak linear relationship between C trough and the corresponding AUC/MIC (r = 0.235). ROC curves for achieving an AUC/MIC of 300 suggested that the initial C trough at 10 μg/mL could be used as a cut-off value with a sensitivity of 90.5% and a specificity of 44%. Although persistent bacteremia at 48-72 hours after vancomycin administration was observed more frequently when the initial C trough was < 10 μg/mL and initial AUC/MIC was < 300, initial AUC/MIC < 300 was the only risk factor associated with persistent bacteremia at 48-72 hours (adjusted OR 3.05; 95% CI, 1.07-8.68). Initial C trough and AUC/MIC were not associated with 30-day mortality. Although there was a weak relationship between C trough and AUC/MIC, initial AUC/MIC < 300 could be used as a predictor of persistent MRSA bacteremia at 48-72 hours. Further prospective data on optimal vancomycin dosing are necessary to improve clinical and microbiological outcomes in pediatric MRSA bacteremia.
Collapse
Affiliation(s)
- Reenar Yoo
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hyejin So
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Euri Seo
- Department of Pediatrics, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Republic of Korea
| | - Mina Kim
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jina Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
- * E-mail:
| |
Collapse
|
50
|
Ferrari F, Benegni S, Marinari E, Haiberger R, Garisto C, Rizza A, Giorni C, Quattrone MG, Arpicco S, Muntoni E, Milla P, Ricci Z. Vancomycin concentrations during cardiopulmonary bypass in pediatric cardiac surgery: a prospective study. Perfusion 2021; 37:553-561. [PMID: 33789546 DOI: 10.1177/02676591211006828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Few data are available regarding intraoperative plasma concentrations of vancomycin administered as prophylaxis in pediatric cardiac surgery. The aims of this study were to investigate during pediatric cardiac surgery with cardiopulmonary bypass(CPB) the attainment of the area-under-the-curve of the vancomycin serum concentrations versus time over surgery to minimum inhibitory concentration ratio(AUCintra/MIC) of 400 (mg × h)/l and/or a target concentration of 15-20 mg/l. METHODS In a prospective study, 40 patients divided into four subgroups (neonates, infants, children <10 years-old, ⩾10 years-old) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were enrolled. A slow vancomycin bolus of 20 mg/kg, up to a maximum dose of 1000 mg was administered before skin incision and a further dose of 10 mg/kg (up to 500 mg) at CPB start. Vancomycin samples were collected intraoperatively at four time points. RESULTS The median (interquartile range) age was 241.5 days (47-3898) and the median weight was 7.1 kg (3.1-37). The median AUCintra/MIC was 254.73 (165.89-508.06). In 11 patients the AUCintra/MIC target was not reached. Neonates displayed the lowest AUCintra/MIC values, and these were significantly lower than those of children ⩾10 years old (p = 0.02). Vancomycin concentrations were above the maximal target of 20 mg/l in 82.5% and 80% of patients at surgery and CPB start, respectively. At CPB and surgery end, 42.5% of patients showed vancomycin concentrations above 20 mg/l and 42.5% below 15 mg/l. Patients⩾10 years old showed the highest peak values whereas neonates were those with the lowest troughs. AUCintra/MIC correlated with age(r:0.36, p = 0.02), weight(r:0.35, p = 0.03), intraoperative protein value(r:0.40, p = 0.01), CPB priming volume/kg(r:-0.33, p = 0.04), CPB duration(r:0.36, p = 0.02) and vancomycin troughs(r:0.35, p = 0.04). CONCLUSIONS An AUCintra/MIC ⩾400 target was not reached in one-quarter of children undergoing heart surgery. Vancomycin peaked before the start of surgery and neonates were those with the lowest troughs. Vancomycin concentrations are affected by CPB hemodilution and by patients' age and weight.
Collapse
Affiliation(s)
- Fiorenza Ferrari
- Intensive Care Unit, I.R.C.C.S. Fondazione Policlinico San Matteo, Pavia, Italy
| | - Simona Benegni
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Eleonora Marinari
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roberta Haiberger
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Cristiana Garisto
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Rizza
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Chiara Giorni
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | | | - Silvia Arpicco
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Elisabetta Muntoni
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Paola Milla
- Department of Drug Science and Technology, University of Turin, Turin, Italy
| | - Zaccaria Ricci
- Azienda Ospedaliero Universitaria Meyer, Firenze, Italy.,Università di Firenze, Firenze, Italy
| |
Collapse
|