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Roger C. Understanding antimicrobial pharmacokinetics in critically ill patients to optimize antimicrobial therapy: A narrative review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:287-298. [PMID: 39035618 PMCID: PMC11258509 DOI: 10.1016/j.jointm.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 07/23/2024]
Abstract
Effective treatment of sepsis not only demands prompt administration of appropriate antimicrobials but also requires precise dosing to enhance the likelihood of patient survival. Adequate dosing refers to the administration of doses that yield therapeutic drug concentrations at the infection site. This ensures a favorable clinical and microbiological response while avoiding antibiotic-related toxicity. Therapeutic drug monitoring (TDM) is the recommended approach for attaining these goals. However, TDM is not universally available in all intensive care units (ICUs) and for all antimicrobial agents. In the absence of TDM, healthcare practitioners need to rely on several factors to make informed dosing decisions. These include the patient's clinical condition, causative pathogen, impact of organ dysfunction (requiring extracorporeal therapies), and physicochemical properties of the antimicrobials. In this context, the pharmacokinetics of antimicrobials vary considerably between different critically ill patients and within the same patient over the course of ICU stay. This variability underscores the need for individualized dosing. This review aimed to describe the main pathophysiological changes observed in critically ill patients and their impact on antimicrobial drug dosing decisions. It also aimed to provide essential practical recommendations that may aid clinicians in optimizing antimicrobial therapy among critically ill patients.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Nîmes, France
- UR UM 103 IMAGINE (Initial Management and prévention of orGan failures IN critically ill patiEnts), Faculty of Medicine, Montpellier University, Montpellier, France
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Westra N, Kruithof PD, Croes S, van Geel RMJM, Hendriks LEL, Touw DJ, Oude Munnink TH, Mian P. Systematic Evaluation of Osimertinib Population Pharmacokinetic Models in a Cohort of Dutch Adults with Non-Small Cell Lung Cancer. Eur J Drug Metab Pharmacokinet 2024; 49:517-526. [PMID: 38878145 PMCID: PMC11199264 DOI: 10.1007/s13318-024-00904-5] [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] [Accepted: 06/04/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND AND OBJECTIVE Several population pharmacokinetic (popPK) studies have been reported that can guide the prediction of osimertinib plasma concentrations in individual patients. It is currently unclear which popPK model offers the best predictive performance and which popPK models are most suitable for nonadherence management and model-informed precision dosing. Therefore, the objective of this study was to externally validate all osimertinib popPK models available in the current literature. METHODS Published popPK models for osimertinib were constructed using NONMEM version 7.4.4. The predictive quality of the identified models was assessed with goodness-of-fit (GoF) plots, conditional weighted residuals (CWRES) plots and a prediction-corrected visual predictive check (pcVPC) for osimertinib and its active metabolite AZ5104. A subset from the Dutch OSIBOOST trial, where 11 patients with low osimertinib exposure were included, was used as evaluation cohort. RESULTS The population GoF plots for all four models poorly followed the line of identity. For the individual GoF plots, all models performed comparable and were closely distributed among the line of identity. CWRES of the four models were skewed. The pcVPCs of all four models showed a similar trend, where all observed concentrations fell in the simulated shaded areas, but in the lower region of the simulated areas. CONCLUSION All four popPK models can be used to individually predict osimertinib concentrations in patients with low osimertinib exposure. For population predictions, all four popPK models performed poorly in patients with low osimertinib exposure. A novel popPK model with good predictive performance should be developed for patients with low osimertinib exposure. Ideally, the cause for the relatively low osimertinib exposure in our evaluation cohort should be known. CLINICAL TRIALS REGISTRATION NCT03858491.
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Affiliation(s)
- Niels Westra
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paul D Kruithof
- Department of Clinical Pharmacy and Toxicology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Sander Croes
- Department of Clinical Pharmacy and Toxicology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Robin M J M van Geel
- Department of Clinical Pharmacy and Toxicology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Lizza E L Hendriks
- Department of Pulmonary Diseases, GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Thijs H Oude Munnink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Pokhriyal SC, Tan EFS, Bhatt PK, Khan AA, Pasha MN, Pierre L, Panigrahi K. Assay Interference Causing Persistently Elevated Vancomycin Levels Leading to Treatment Failure and Fatal Outcome. Cureus 2024; 16:e61943. [PMID: 38978903 PMCID: PMC11230609 DOI: 10.7759/cureus.61943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/10/2024] Open
Abstract
In patients receiving vancomycin therapy, serum drug levels are routinely monitored to ensure therapeutic dosing and minimize toxicity. In rare cases, vancomycin levels may be falsely or persistently elevated without any apparent cause. In this case report, we explore a rare case of persistently elevated vancomycin levels despite discontinuation of the drug for days. This is a case of a 69-year-old female admitted for altered mental status secondary to sepsis from leg cellulitis. Antibiotic therapy included vancomycin. To ensure proper dosing, vancomycin trough levels were collected before the fourth dose, and the result showed a high value of 39 ug/ml. Vancomycin doses were adjusted as per the Bayesian dosing software, and the same remained to be in supratherapeutic levels. The patient eventually deteriorated, and due to persistently high vancomycin levels, the antibiotic regimen was switched to a different antibiotic. Despite normal renal functions, the vancomycin levels remained high, between 27 ug/ml and 32 ug/ml, even in the absence of any further doses. Subsequently, vancomycin serum concentration was determined by another method using high-performance liquid chromatography (HPLC). Blood cultures grew both coagulase-negative Staphylococcus aureus and Achromobacter xylosoxidans. Vancomycin levels remained high a week after discontinuation of the drug. Vancomycin by HPLC assay eventually showed that vancomycin was undetectable in the blood, but, unfortunately, the results came at a time when the patient had already expired. In conclusion, clinicians should maintain a high level of suspicion if persistently higher vancomycin levels cannot be accounted for by renal function or other causes. In patients with persistently high vancomycin levels who continue to clinically deteriorate, it is crucial to consider that assay interference can result in inaccurately elevated vancomycin levels.
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Affiliation(s)
- Sindhu C Pokhriyal
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | | | | | - Ahmad Ali Khan
- Pulmonary and Critical Care Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | - Muhammad N Pasha
- Pulmonary and Critical Care Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | - Luckencia Pierre
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
| | - Kalpana Panigrahi
- Internal Medicine, One Brooklyn Health-Interfaith Medical Center, Brooklyn, USA
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Alsultan A, Dasuqi SA, Almohaizeie A, Aljutayli A, Aljamaan F, Omran RA, Alolayan A, Hamad MA, Alotaibi H, Altamimi S, Alghanem SS. External Validation of Obese/Critically Ill Vancomycin Population Pharmacokinetic Models in Critically Ill Patients Who Are Obese. J Clin Pharmacol 2024; 64:353-361. [PMID: 37862131 DOI: 10.1002/jcph.2375] [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: 07/27/2023] [Accepted: 10/17/2023] [Indexed: 10/22/2023]
Abstract
Obesity combined with critical illness might increase the risk of acquiring infections and hence mortality. In this patient population the pharmacokinetics of antimicrobials vary significantly, making antimicrobial dosing challenging. The objective of this study was to assess the predictive performance of published population pharmacokinetic models of vancomycin in patients who are critically ill or obese for a cohort of critically ill patients who are obese. This was a multi-center retrospective study conducted at 2 hospitals. Adult patients with a body mass index of ≥30 kg/m2 were included. PubMed was searched for published population pharmacokinetic studies in patients who were critically ill or obese. External validation was performed using Monolix software. A total of 4 models were identified in patients who were obese and 5 models were identified in patients who were critically ill. In total, 138 patients who were critically ill and obese were included, and the most accurate models for these patients were the Goti and Roberts models. In our analysis, models in patients who were critically ill outperformed models in patients who were obese. When looking at the most accurate models, both the Goti and the Roberts models had patient characteristics similar to ours in terms of age and creatinine clearance. This indicates that when selecting the proper model to apply in practice, it is important to account for all relevant variables, besides obesity.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Shereen A Dasuqi
- Department of Pharmacy, King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Abdullah Almohaizeie
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abdullah Aljutayli
- Department of Pharmaceutics, Faculty of Pharmacy, Qassim University, Riyadh, Saudi Arabia
| | - Fadi Aljamaan
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Critical Care Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Rasha A Omran
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy, University of Jordan, Amman, Jordan
| | - Abdulaziz Alolayan
- Pharmacy Department, Prince Sultan Military Medical City, Riyadh, Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
| | - Mohammed A Hamad
- Critical Care Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
- Department of Acute Medicine, Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Wirral, UK
| | - Haifa Alotaibi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sarah Altamimi
- Pharmaceutical Care Division, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sarah S Alghanem
- Department of Pharmacy Practice, College of Pharmacy at Kuwait University, Safat, Kuwait
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Han YJ, Jang W, Kim JS, Kim HJ, Suh SY, Cho YS, Park JD, Lee B. Development of a model to predict vancomycin serum concentration during continuous infusion of vancomycin in critically ill pediatric patients. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY : OFFICIAL JOURNAL OF THE KOREAN PHYSIOLOGICAL SOCIETY AND THE KOREAN SOCIETY OF PHARMACOLOGY 2024; 28:121-127. [PMID: 38414395 PMCID: PMC10902586 DOI: 10.4196/kjpp.2024.28.2.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/29/2024]
Abstract
Vancomycin is a frequently used antibiotic in intensive care units, and the patient's renal clearance affects the pharmacokinetic characteristics of vancomycin. Several advantages have been reported for vancomycin continuous intravenous infusion, but studies on continuous dosing regimens based on patients' renal clearance are insufficient. The aim of this study was to develop a vancomycin serum concentration prediction model by factoring in a patient's renal clearance. Children admitted to our institution between July 1, 2021, and July 31, 2022 with records of continuous infusion of vancomycin were included in the study. Sex, age, height, weight, vancomycin dose by weight, interval from the start of vancomycin administration to the time of therapeutic drug monitoring sampling, and vancomycin serum concentrations were analyzed with the linear regression analysis of the mixed effect model. Univariable regression analysis was performed using the vancomycin serum concentration as a dependent variable. It showed that vancomycin dose (p < 0.001) and serum creatinine (p = 0.007) were factors that had the most impact on vancomycin serum concentration. Vancomycin serum concentration was affected by vancomycin dose (p < 0.001) and serum creatinine (p = 0.001) with statistical significance, and a multivariable regression model was obtained as follows: Vancomycin serum concentration (mg/l) = -1.296 + 0.281 × vancomycin dose (mg/kg) + 20.458 × serum creatinine (mg/dl) (adjusted coefficient of determination, R2 = 0.66). This prediction model is expected to contribute to establishing an optimal continuous infusion regimen for vancomycin.
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Affiliation(s)
- Yu Jin Han
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - Wonjin Jang
- Department of Pediatrics, Seoul National University Hospital and College of Medicine, Seoul 03080, Korea
| | - Jung Sun Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul 03760, Korea
| | - Hyun Jeong Kim
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - Sung Yun Suh
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - Yoon Sook Cho
- Department of Pharmacy, Seoul National University Hospital, Seoul 03080, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University Hospital and College of Medicine, Seoul 03080, Korea
| | - Bongjin Lee
- Department of Pediatrics, Seoul National University Hospital and College of Medicine, Seoul 03080, Korea
- Innovative Medical Technology Research Institute, Seoul National University Hospital, Seoul 03080, Korea
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Liu HX, Tang BH, van den Anker J, Hao GX, Zhao W, Zheng Y. Population pharmacokinetics of antibacterial agents in the older population: a literature review. Expert Rev Clin Pharmacol 2024; 17:19-31. [PMID: 38131668 DOI: 10.1080/17512433.2023.2295009] [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: 10/08/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Older individuals face an elevated risk of developing bacterial infections. The optimal use of antibacterial agents in this population is challenging because of age-related physiological alterations, changes in pharmacokinetics (PK) and pharmacodynamics (PD), and the presence of multiple underlying diseases. Therefore, population pharmacokinetics (PPK) studies are of great importance for optimizing individual treatments and prompt identification of potential risk factors. AREA COVERED Our search involved keywords such as 'elderly,' 'old people,' and 'geriatric,' combined with 'population pharmacokinetics' and 'antibacterial agents.' This comprehensive search yielded 11 categories encompassing 28 antibacterial drugs, including vancomycin, ceftriaxone, meropenem, and linezolid. Out of 127 studies identified, 26 (20.5%) were associated with vancomycin, 14 (11%) with meropenem, and 14 (11%) with piperacillin. Other antibacterial agents were administered less frequently. EXPERT OPINION PPK studies are invaluable for elucidating the characteristics and relevant factors affecting the PK of antibacterial agents in the older population. Further research is warranted to develop and validate PPK models for antibacterial agents in this vulnerable population.
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Affiliation(s)
- Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo-Hao Tang
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC, USA
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Pharmacy, The Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Clinical Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
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Taylor ZL, Poweleit EA, Paice K, Somers KM, Pavia K, Vinks AA, Punt N, Mizuno T, Girdwood ST. Tutorial on model selection and validation of model input into precision dosing software for model-informed precision dosing. CPT Pharmacometrics Syst Pharmacol 2023; 12:1827-1845. [PMID: 37771190 PMCID: PMC10725261 DOI: 10.1002/psp4.13056] [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] [Received: 03/12/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
There has been rising interest in using model-informed precision dosing to provide personalized medicine to patients at the bedside. This methodology utilizes population pharmacokinetic models, measured drug concentrations from individual patients, pharmacodynamic biomarkers, and Bayesian estimation to estimate pharmacokinetic parameters and predict concentration-time profiles in individual patients. Using these individualized parameter estimates and simulated drug exposure, dosing recommendations can be generated to maximize target attainment to improve beneficial effect and minimize toxicity. However, the accuracy of the output from this evaluation is highly dependent on the population pharmacokinetic model selected. This tutorial provides a comprehensive approach to evaluating, selecting, and validating a model for input and implementation into a model-informed precision dosing program. A step-by-step outline to validate successful implementation into a precision dosing tool is described using the clinical software platforms Edsim++ and MwPharm++ as examples.
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Affiliation(s)
- Zachary L. Taylor
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Ethan A. Poweleit
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of Biomedical InformaticsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Biomedical InformaticsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Research in Patient ServicesCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Kelli Paice
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Critical Care Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Katherine M. Somers
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Critical Care Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Hematology and Oncology, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Kathryn Pavia
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Division of Critical Care Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Alexander A. Vinks
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Research in Patient ServicesCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Nieko Punt
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
- MedimaticsMaastrichtThe Netherlands
| | - Tomoyuki Mizuno
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Sonya Tang Girdwood
- Division of Clinical PharmacologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
- Division of Hospital Medicine, Department of PediatricsCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
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Khromov T, Dihazi GH, Brockmeyer P, Fischer A, Streit F. 24/7 Therapeutic Drug Monitoring of Beta-Lactam Antibiotics with CLAM-2000. Antibiotics (Basel) 2023; 12:1526. [PMID: 37887227 PMCID: PMC10604791 DOI: 10.3390/antibiotics12101526] [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: 09/17/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the CLAM-2000 automated preanalytical sample preparation module with integrated liquid chromatography-mass spectrometry/mass spectrometry (LC-MS/MS) as a method for 24/7 therapeutic drug monitoring (TDM) of beta-lactam antibiotics in routine clinical diagnostics. METHODS Method validation was performed using quality control samples. Method comparison was performed with routine samples from patients treated with beta-lactam antibiotics. RESULTS The determination of piperacillin, meropenem, ceftazidime, flucloxacillin, and cefotaxime was performed using D5-piperacillin and D6-meropenem as internal standards. The linearity of the method was within the therapeutic range of beta-lactam antibiotics. The imprecision and accuracy data obtained from quality control samples were within 15%, and the imprecision of patient samples on the instrument was less than the 5% coefficient of variation (CV). Internal standards stored in the instrument at 9 °C for at least one week were stable, which facilitated reagent use and storage. CONCLUSION The CLAM-2000 (Shimadzu, Kyoto, Japan) provides reproducible results as an established routine instrument and is a useful tool for 24/7 TDM of beta-lactam antibiotics in routine clinical diagnostics.
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Affiliation(s)
- Tatjana Khromov
- Department of Clinical Chemistry, University Medical Center Goettingen, Robert-Koch Str. 40, D-37075 Goettingen, Germany; (G.H.D.); (A.F.); (F.S.)
| | - Gry Helene Dihazi
- Department of Clinical Chemistry, University Medical Center Goettingen, Robert-Koch Str. 40, D-37075 Goettingen, Germany; (G.H.D.); (A.F.); (F.S.)
| | - Phillipp Brockmeyer
- Department of Oral and Maxillofacial Surgery, University Medical Center Goettingen, Robert-Koch Str. 40, D-37075 Goettingen, Germany;
| | - Andreas Fischer
- Department of Clinical Chemistry, University Medical Center Goettingen, Robert-Koch Str. 40, D-37075 Goettingen, Germany; (G.H.D.); (A.F.); (F.S.)
| | - Frank Streit
- Department of Clinical Chemistry, University Medical Center Goettingen, Robert-Koch Str. 40, D-37075 Goettingen, Germany; (G.H.D.); (A.F.); (F.S.)
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Williams P, Cotta MO, Abdul-Aziz MH, Wilks K, Farkas A, Roberts JA. In silico Evaluation of a Vancomycin Dosing Guideline Among Adults with Serious Infections. Ther Drug Monit 2023; 45:631-636. [PMID: 37199397 DOI: 10.1097/ftd.0000000000001102] [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: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND This study aimed to compare the achievement of pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for vancomycin using a newly developed dosing guideline with product-information-based dosing in the treatment of adult patients with serious infections. METHODS In silico product-information- and guideline-based dosing simulations for vancomycin were performed across a range of doses and patient characteristics, including body weight, age, and renal function at 36-48 and 96 hours, using a pharmacokinetic model derived from a seriously ill patient population. The median simulated concentration and area under the 24-hour concentration-time curve (AUC 0-24 ) were used to measure predefined therapeutic, subtherapeutic, and toxicity PK-PD targets. RESULTS Ninety-six dosing simulations were performed. The pooled median trough concentration target with guideline-based dosing at 36 and 96 hours was achieved in 27.1% (13/48) and 8.3% (7/48) of simulations, respectively. The pooled median AUC 0-24 /minimum inhibitory concentration ratio with guideline-based dosing at 48 and 96 hours was attained in 39.6% (19/48) and 27.1% (13/48) of simulations, respectively. Guideline-based dosing simulations yielded improved trough target attainment compared with product-information-based dosing at 36 hours and significantly less subtherapeutic drug exposure. The toxicity threshold was exceeded in 52.1% (25/48) and 0% (0/48) for guideline- and product-information-information-based dosing, respectively ( P < 0.001). CONCLUSIONS A Critical care vancomycin dosing guideline appeared slightly more effective than standard dosing, as per product information, in achieving PK-PD exposure associated with an increased likelihood of effectiveness. In addition, this guideline significantly reduced the risk of subtherapeutic exposure. The risk of exceeding toxicity thresholds, however, was greater with the guideline, and further investigation is suggested to improve dosing accuracy and sensitivity.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West, New York, New York
- Optimum Dosing Strategies, Bloomingdale, New Jersey
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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Contejean A, Maillard A, Canouï E, Kernéis S, Fantin B, Bouscary D, Parize P, Garcia-Vidal C, Charlier C. Advances in antibacterial treatment of adults with high-risk febrile neutropenia. J Antimicrob Chemother 2023; 78:2109-2120. [PMID: 37259598 DOI: 10.1093/jac/dkad166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND High-risk febrile neutropenia (HR-FN) is a life-threatening complication in patients with haematological malignancies or receiving myelosuppressive chemotherapy. Since the last international guidelines were published over 10 years ago, there have been major advances in the understanding and management of HR-FN, including on antibiotic pharmacokinetics and discontinuation/de-escalation strategies. OBJECTIVES Summarizing major advances in the field of antibacterial therapy in patients with HR-FN: empirical therapy, pharmacokinetics of antibiotics and antibiotic stewardship. SOURCES Narrative review based on literature review from PubMed. We focused on studies published between 2010 and 2023 about the pharmacokinetics of antimicrobials, management of antimicrobial administration, and discontinuation/de-escalation strategies. We did not address antimicrobial prophylaxis, viral or fungal infections. CONTENT Several high-quality publications have highlighted important modifications of antibiotic pharmacokinetics in HR-FN, with standard dosages exposing patients to underdosing. These recent clinical and population pharmacokinetics studies help improve management protocols with optimized initial dosing and infusion rules for β-lactams, vancomycin, daptomycin and amikacin; they highlight the potential benefits of therapeutic drug monitoring. A growing body of evidence also shows that antibiotic discontinuation/de-escalation strategies are beneficial for bacterial ecology and patients' outcome. We further discuss methods and limitations for implementation of such protocols in haematology. IMPLICATIONS We highlight recent information about the management of antibacterial therapy in HR-FN that might be considered in updated guidelines for HR-FN management.
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Affiliation(s)
- Adrien Contejean
- Service d'Hématologie, Centre Hospitalier Annecy Genevois, 1 Avenue de l'hôpital, F-74370 Epagny Metz-Tessy, France
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
| | - Alexis Maillard
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Etienne Canouï
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Solen Kernéis
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Équipe de Prévention du Risque Infectieux, AP-HP, Hôpital Bichat, F-75018 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
| | - Bruno Fantin
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Département de Médecine Interne, AP-HP, Hôpital Beaujon, F-92110, Clichy, France
| | - Didier Bouscary
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Service d'Hématologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Perrine Parize
- Service de Maladies Infectieuses, AP-HP, APHP.CUP, Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- CIBERINF, Madrid, Spain
| | - Caroline Charlier
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- National Reference Center Listeriosis WHO Collaborating Center, Institut Pasteur, F-75015 Paris, France
- Biology of Infection Unit, Inserm U1117 Institut Pasteur, F-75015 Paris, France
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11
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Chan A, Peck R, Gibbs M, van der Schaar M. Synthetic Model Combination: A new machine-learning method for pharmacometric model ensembling. CPT Pharmacometrics Syst Pharmacol 2023; 12:953-962. [PMID: 37042155 PMCID: PMC10349196 DOI: 10.1002/psp4.12965] [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: 10/13/2022] [Revised: 02/20/2023] [Accepted: 03/20/2023] [Indexed: 04/13/2023] Open
Abstract
When aiming to make predictions over targets in the pharmacological setting, a data-focused approach aims to learn models based on a collection of labeled examples. Unfortunately, data sharing is not always possible, and this can result in many different models trained on disparate populations, leading to the natural question of how best to use and combine them when making a new prediction. Previous work has focused on global model selection or ensembling, with the result of a single final model across the feature space. Machine-learning models perform notoriously poorly on data outside their training domain, however, due to a problem known as covariate shift, and so we argue that when ensembling models the weightings for individual instances must reflect their respective domains-in other words, models that are more likely to have seen information on that instance should have more attention paid to them. We introduce a method for such an instance-wise ensembling of models called Synthetic Model Combination (SMC), including a novel representation learning step for handling sparse high-dimensional domains. We demonstrate the use of SMC on an example with dosing predictions for vancomycin, although emphasize the applicability of the method to any scenario involving the use of multiple models.
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Affiliation(s)
- Alexander Chan
- Department of Applied Mathematics and Theoretical PhysicsUniversity of CambridgeCambridgeUK
| | - Richard Peck
- Pharma Research and Development (pRED), Roche Innovation CenterBaselSwitzerland
- Department of Pharmacology & TherapeuticsUniversity of LiverpoolLiverpoolUK
- Cambridge Centre for AI in MedicineUniversity of CambridgeCambridgeUK
| | - Megan Gibbs
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZenecaGaithersburgMarylandUSA
| | - Mihaela van der Schaar
- Department of Applied Mathematics and Theoretical PhysicsUniversity of CambridgeCambridgeUK
- Cambridge Centre for AI in MedicineUniversity of CambridgeCambridgeUK
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12
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Singh FA, Afzal N, Smithline SJ, Thalhauser CJ. Assessing the performance of QSP models: biology as the driver for validation. J Pharmacokinet Pharmacodyn 2023:10.1007/s10928-023-09871-x. [PMID: 37386340 DOI: 10.1007/s10928-023-09871-x] [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: 11/28/2022] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
Validation of a quantitative model is a critical step in establishing confidence in the model's suitability for whatever analysis it was designed. While processes for validation are well-established in the statistical sciences, the field of quantitative systems pharmacology (QSP) has taken a more piecemeal approach to defining and demonstrating validation. Although classical statistical methods can be used in a QSP context, proper validation of a mechanistic systems model requires a more nuanced approach to what precisely is being validated, and what role said validation plays in the larger context of the analysis. In this review, we summarize current thoughts of QSP validation in the scientific community, contrast the aims of statistical validation from several contexts (including inference, pharmacometrics analysis, and machine learning) with the challenges faced in QSP analysis, and use examples from published QSP models to define different stages or levels of validation, any of which may be sufficient depending on the context at hand.
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Affiliation(s)
- Fulya Akpinar Singh
- Genmab US, Inc., 777 Scudders Mill Rd Bldg 2 4th Floor, Plainsboro, NJ, 08536, USA
| | - Nasrin Afzal
- Genmab US, Inc., 777 Scudders Mill Rd Bldg 2 4th Floor, Plainsboro, NJ, 08536, USA
| | - Shepard J Smithline
- Genmab US, Inc., 777 Scudders Mill Rd Bldg 2 4th Floor, Plainsboro, NJ, 08536, USA
| | - Craig J Thalhauser
- Genmab US, Inc., 777 Scudders Mill Rd Bldg 2 4th Floor, Plainsboro, NJ, 08536, USA.
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13
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Gorham J, Taccone FS, Hites M. Therapeutic Drug Monitoring of Antimicrobials in Critically Ill Obese Patients. Antibiotics (Basel) 2023; 12:1099. [PMID: 37508195 PMCID: PMC10376599 DOI: 10.3390/antibiotics12071099] [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: 05/10/2023] [Revised: 06/14/2023] [Accepted: 06/21/2023] [Indexed: 07/30/2023] Open
Abstract
Obesity is a significant global public health concern that is associated with an elevated risk of comorbidities as well as severe postoperative and nosocomial infections. The treatment of infections in critically ill obese patients can be challenging because obesity affects the pharmacokinetics and pharmacodynamics of antibiotics, leading to an increased risk of antibiotic therapy failure and toxicity due to inappropriate dosages. Precision dosing of antibiotics using therapeutic drug monitoring may help to improve the management of this patient population. This narrative review outlines the pharmacokinetic and pharmacodynamic changes that result from obesity and provides a comprehensive critical review of the current available data on dosage adjustment of antibiotics in critically ill obese patients.
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Affiliation(s)
- Julie Gorham
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious Diseases, Hôpital Universitaire de Bruxelles (H.U.B), 1070 Brussels, Belgium
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Setiawan E, Cotta MO, Roberts JA, Abdul-Aziz MH. A Systematic Review on Antimicrobial Pharmacokinetic Differences between Asian and Non-Asian Adult Populations. Antibiotics (Basel) 2023; 12:antibiotics12050803. [PMID: 37237706 DOI: 10.3390/antibiotics12050803] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/28/2023] Open
Abstract
While the relevance of inter-ethnic differences to the pharmacokinetic variabilities of antimicrobials has been reported in studies recruiting healthy subjects, differences in antimicrobial pharmacokinetics between Asian and non-Asian patients with severe pathologic conditions require further investigation. For the purpose of describing the potential differences in antimicrobial pharmacokinetics between Asian and non-Asian populations, a systematic review was performed using six journal databases and six theses/dissertation databases (PROSPERO record CRD42018090054). The pharmacokinetic data of healthy volunteers and non-critically ill and critically ill patients were reviewed. Thirty studies on meropenem, imipenem, doripenem, linezolid, and vancomycin were included in the final descriptive summaries. In studies recruiting hospitalised patients, inconsistent differences in the volume of distribution (Vd) and drug clearance (CL) of the studied antimicrobials between Asian and non-Asian patients were observed. Additionally, factors other than ethnicity, such as demographic (e.g., age) or clinical (e.g., sepsis) factors, were suggested to better characterise these pharmacokinetic differences. Inconsistent differences in pharmacokinetic parameters between Asian and non-Asian subjects/patients may suggest that ethnicity is not an important predictor to characterise interindividual pharmacokinetic differences between meropenem, imipenem, doripenem, linezolid, and vancomycin. Therefore, the dosing regimens of these antimicrobials should be adjusted according to patients' demographic or clinical characteristics that can better describe pharmacokinetic differences.
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Affiliation(s)
- Eko Setiawan
- University of Queensland Centre for Clinical Research [UQCCR], Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia
- Department of Clinical and Community Pharmacy, Center for Medicines Information and Pharmaceutical Care [CMIPC], Faculty of Pharmacy, University of Surabaya, Surabaya 60293, Indonesia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research [UQCCR], Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research [UQCCR], Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - Mohd Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research [UQCCR], Faculty of Medicine, The University of Queensland, Brisbane 4006, Australia
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15
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Belabbas T, Yamada T, Egashira N, Hirota T, Suetsugu K, Mori Y, Kato K, Akashi K, Ieiri I. Population pharmacokinetic model and dosing optimization of vancomycin in hematologic malignancies with neutropenia and augmented renal clearance. J Infect Chemother 2023; 29:391-400. [PMID: 36682608 DOI: 10.1016/j.jiac.2023.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
AIM Data on the pharmacokinetics (PK) and area under the curve (AUC)-based dosing strategy of vancomycin (VCM) in hematologic malignancies are limited. According to our preliminary narrative review, only a few population PK analyses in hematologic malignancies have been performed. Therefore, we aimed to develop a population PK model, investigate the factors influencing VCM PK, and propose an optimal dosing regimen for hematologic malignancies. METHODS A retrospective study was conducted in patients with underlying hematologic malignancies treated with VCM. A total of 148 patients were enrolled for population PK modeling. Simulation analyses were performed to identify dosing regimens achieving a target exposure of AUC0-24 of 400-600 mg h/L at the steady-state. RESULTS The VCM PK data were best described with a one-compartment model. Significant covariates included creatinine clearance (Ccr), diagnosis of acute myeloid leukemia (AML) and neutropenia on VCM clearance (CL), and body weight (WT) on the volume of distribution (Vd). The typical values of CL and Vd were 3.09 L/h (normalized to Ccr value of 90 mL/min) and 122 L/70 kg, respectively. Concerning the effect on VCM dosing, AML patients required 15% higher doses than non-AML patients, independently of renal function. In contrast, for neutropenic patients, only those with augmented renal clearance (ARC, Ccr value ≥ 130 mL/min) required a 10% dose increase compared to non-neutropenic patients. CONCLUSION AML patients with neutropenia and ARC represent a critical population with a higher risk of VCM underexposure. Thus, individualized dosing adjustment and therapeutic drug monitoring are strongly recommended.
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Affiliation(s)
- Tassadit Belabbas
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takaaki Yamada
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nobuaki Egashira
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan; Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kimitaka Suetsugu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ichiro Ieiri
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan; Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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16
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Arensman Hannan KN, Rivera CG, Fewel N. Vancomycin AUC values estimated with trough-only data: Accuracy in an adult academic medical center population. Am J Health Syst Pharm 2023; 80:452-456. [PMID: 36525590 DOI: 10.1093/ajhp/zxac372] [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: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Vancomycin area under the concentration-time curve (AUC) can be calculated using steady-state serum peak and trough concentrations; however, compared to traditional trough-only monitoring, this approach requires an additional blood sample. Recently published data demonstrated vancomycin AUC estimations using trough-only data with a volume of distribution (Vd) model incorporating age and actual body weight were reasonably accurate and precise in a veteran population. This study sought to extend these methods to a Mayo Clinic adult population. METHODS A retrospective, observational cohort of adult patients with documented steady-state vancomycin peak and trough concentrations was evaluated. Vancomycin AUCs were estimated using trough-only data, and 4 Vd models were assessed for accuracy and precision. Estimated AUCs were compared to AUCs calculated using 1-compartment intermittent infusion equations and steady-state peak and trough ("peak-trough") data. RESULTS The study population (N = 95) was 46% female, with a median age of 59 years and a median weight of 97 kg. Using the VancoPK equation Vd = 0.29 (age in y) + 0.33 (actual weight in kg) + 11, the mean peak-trough and estimated trough-only AUC were 533 and 534, respectively, with a correlation of 0.936. The root mean square error was 47.7, meaning about 95% of AUCs were within 95 mg · h/L of peak-trough AUCs. CONCLUSIONS Accuracy and precision of Vancomycin AUC estimations using trough-only data and the described Vd model were demonstrated in a Mayo Clinic cohort. Targeting an estimated AUC of 500 mg · h/L using the VancoPK model would likely result in an actual AUC within 400 to 600 mg · h/L.
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Affiliation(s)
| | | | - Nathan Fewel
- Department of Pharmacy, Central Texas Veterans Health Care System, Temple, TX, USA
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17
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Impact of Vancomycin Loading Doses and Dose Escalation on Glomerular Function and Kidney Injury Biomarkers in a Translational Rat Model. Antimicrob Agents Chemother 2023; 67:e0127622. [PMID: 36648224 PMCID: PMC9933721 DOI: 10.1128/aac.01276-22] [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: 01/18/2023] Open
Abstract
Vancomycin-induced kidney injury is common, and outcomes in humans are well predicted by animal models. This study employed our translational rat model to investigate temporal changes in the glomerular filtration rate (GFR) and correlations with kidney injury biomarkers related to various vancomycin dosing strategies. First, Sprague-Dawley rats received allometrically scaled loading doses or standard doses. Rats that received a loading dose had low GFRs and increased urinary injury biomarkers (kidney injury molecule 1 [KIM-1] and clusterin) that persisted through day 2 compared to those that did not receive a loading dose. Second, we compared low and high allometrically scaled vancomycin doses to a positive acute kidney injury control of high-dose folic acid. Rats in both the low- and high-dose vancomycin groups had higher GFRs on all dosing days than the positive-control group. When the two vancomycin groups were compared, rats that received the low dose had significantly higher GFRs on days 1, 2, and 4. Compared to low-dose vancomycin, the KIM-1 was elevated among rats in the high-dose group on dosing day 3. The GFR correlated most closely with the urinary injury biomarker KIM-1 on all experimental days. Vancomycin loading doses were associated with significant losses of kidney function and elevations of urinary injury biomarkers. In our translational rat model, both the degree of kidney function decline and urinary biomarker increases corresponded to the magnitude of the vancomycin dose (i.e., a higher dose resulted in worse outcomes).
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Implementing Vancomycin Population Pharmacokinetic Models: An App for Individualized Antibiotic Therapy in Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12020301. [PMID: 36830212 PMCID: PMC9952184 DOI: 10.3390/antibiotics12020301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/17/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
In individualized therapy, the Bayesian approach integrated with population pharmacokinetic models (PopPK) for predictions together with therapeutic drug monitoring (TDM) to maintain adequate objectives is useful to maximize the efficacy and minimize the probability of toxicity of vancomycin in critically ill patients. Although there are limitations to implementation, model-informed precision dosing (MIPD) is an approach to integrate these elements, which has the potential to optimize the TDM process and maximize the success of antibacterial therapy. The objective of this work was to present an app for individualized therapy and perform a validation of the implemented vancomycin PopPK models. A pragmatic approach was used for selecting the models of Llopis, Goti and Revilla for developing a Shiny app with R. Through ordinary differential equation (ODE)-based mixed effects models from the mlxR package, the app simulates the concentrations' behavior, estimates whether the model was simulated without variability and predicts whether the model was simulated with variability. Moreover, we evaluated the predictive performance with retrospective trough concentration data from patients admitted to the adult critical care unit. Although there were no significant differences in the performance of the estimates, the Llopis model showed better accuracy (mean 80.88%; SD 46.5%); however, it had greater bias (mean -34.47%, SD 63.38%) compared to the Revilla et al. (mean 10.61%, SD 66.37%) and Goti et al. (mean of 13.54%, SD 64.93%) models. With respect to the RMSE (root mean square error), the Llopis (mean of 10.69 mg/L, SD 12.23 mg/L) and Revilla models (mean of 10.65 mg/L, SD 12.81 mg/L) were comparable, and the lowest RMSE was found in the Goti model (mean 9.06 mg/L, SD 9 mg/L). Regarding the predictions, this behavior did not change, and the results varied relatively little. Although our results are satisfactory, the predictive performance in recent studies with vancomycin is heterogeneous, and although these three models have proven to be useful for clinical application, further research and adaptation of PopPK models is required, as well as implementation in the clinical practice of MIPD and TDM in real time.
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Selig DJ, Reed T, Chung KK, Kress AT, Stewart IJ, DeLuca JP. Hemoperfusion with Seraph 100 Microbind Affinity Blood Filter Unlikely to Require Increased Antibiotic Dosing: A Simulations Study Using a Pharmacokinetic/Pharmacodynamic Approach. Blood Purif 2023; 52:25-31. [PMID: 35526522 DOI: 10.1159/000524457] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/04/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The Seraph® 100 Microbind® Affinity Blood Filter (Seraph 100) is a hemoperfusion device that can remove pathogens from central circulation. However, the effect of Seraph 100 on achieving pharmacodynamic (PD) targets is not well described. We sought to determine the impact of Seraph 100 on ability to achieve PD targets for commonly used antibiotics. METHODS Estimates of Seraph 100 antibiotic clearance were obtained via literature. For vancomycin and gentamicin, published pharmacokinetic models were used to explore the effect of Seraph 100 on ability to achieve probability of target attainment (PTA). For meropenem and imipenem, the reported effect of continuous kidney replacement therapy (CKRT) on achieving PTA was used to extrapolate decisions for Seraph 100. RESULTS Seraph 100 antibiotic clearance is likely less than 0.5 L/h for most antibiotics. Theoretical Seraph 100 clearance up to 0.5 L/h and 2 L/h had a negligible effect on vancomycin PTA in virtual patients with creatinine clearance (CrCl) = 14 mL/min and CrCl >14 mL/min, respectively. Theoretical Seraph 100 clearance up to 0.5 L/h and 2 L/h had a negligible effect on gentamicin PTA in virtual patients with CrCl = 120 mL/min and CrCl <60 mL/min, respectively. CKRT intensity resulting in antibiotic clearance up to 2 L/h generally does not require dose increases for meropenem or imipenem. As Seraph 100 is prescribed intermittently and likely contributes far less to antibiotic clearance, dose increases would also not be required. CONCLUSION Seraph 100 clearance of vancomycin, gentamicin, meropenem, and imipenem is likely clinically insignificant. There is insufficient evidence to recommend increased doses. For aminoglycosides, we recommend extended interval dosing and initiating Seraph 100 at least 30 min to 1 h after completion of infusion to avoid the possibility of interference with maximum concentrations.
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Affiliation(s)
- Daniel J Selig
- Department of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Tyler Reed
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Adrian T Kress
- Department of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Ian J Stewart
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jesse P DeLuca
- Department of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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Chen A, Gupta A, Do DH, Nazer LH. Bayesian method application: Integrating mathematical modeling into clinical pharmacy through vancomycin therapeutic monitoring. Pharmacol Res Perspect 2022; 10:e01026. [PMID: 36398492 PMCID: PMC9672880 DOI: 10.1002/prp2.1026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022] Open
Abstract
The most recent consensus guidelines for dosing and monitoring vancomycin recommended the use of area-under-the-curve with Bayesian estimation for therapeutic monitoring. As this is a modern concept in the practice of clinical pharmacy, the main objective of this review is to introduce the fundamentals of Bayesian estimation and its mathematical application as it relates to vancomycin therapeutic drug monitoring. In addition, we aim to identify pharmacokinetic (PK) software programs that incorporate Bayesian estimation for vancomycin dosing and to describe the PK models utilized in those software programs for the adult population. Twelve software programs that utilize Bayesian estimation were identified, which included: Adult and Pediatric Kinetics, Best Dose, ClinCalc, DoseMeRx, ID-ODS, InsightRx, MwPharm++, NextDose, PrecisePK, TDMx, Tucuxi, and VancoCalc. The software programs varied in the population PK models used as the Bayesian a priori. With the presence of various vancomycin Bayesian software programs, it is important to choose those that utilize PK models reflective of the specific patient population.
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Affiliation(s)
- Ashley Chen
- University of CaliforniaSan DiegoCaliforniaUSA
| | - Anjum Gupta
- University of CaliforniaSan DiegoCaliforniaUSA,PreciseRx IncSan DiegoCaliforniaUSA
| | - Dylan Huy Do
- University of CaliforniaSan DiegoCaliforniaUSA,Canyon Crest AcademySan DiegoCaliforniaUSA
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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
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Gastmans H, Dreesen E, Wicha SG, Dia N, Spreuwers E, Dompas A, Allegaert K, Desmet S, Lagrou K, Peetermans WE, Debaveye Y, Spriet I, Gijsen M. Systematic Comparison of Hospital-Wide Standard and Model-Based Therapeutic Drug Monitoring of Vancomycin in Adults. Pharmaceutics 2022; 14:1459. [PMID: 35890354 PMCID: PMC9320266 DOI: 10.3390/pharmaceutics14071459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/30/2022] [Accepted: 07/08/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to evaluate the predictive performance and predicted doses of a single-model approach or several multi-model approaches compared with the standard therapeutic drug monitoring (TDM)-based vancomycin dosing. We performed a hospital-wide monocentric retrospective study in adult patients treated with either intermittent or continuous vancomycin infusions. Each patient provided two randomly selected pairs of two consecutive vancomycin concentrations. A web-based precision dosing software, TDMx, was used to evaluate the model-based approaches. In total, 154 patients contributed 308 pairs. With standard TDM-based dosing, only 48.1% (148/308) of all of the second concentrations were within the therapeutic range. Across the model-based approaches we investigated, the mean relative bias and relative root mean square error varied from -5.36% to 3.18% and from 24.8% to 28.1%, respectively. The model averaging approach according to the squared prediction errors showed an acceptable bias and was the most precise. According to this approach, the median (interquartile range) differences between the model-predicted and prescribed doses, expressed as mg every 12 h, were 113 [-69; 427] mg, -70 [-208; 120], mg and 40 [-84; 197] mg in the case of subtherapeutic, supratherapeutic, and therapeutic exposure at the second concentration, respectively. These dose differences, along with poor target attainment, suggest a large window of opportunity for the model-based TDM compared with the standard TDM-based vancomycin dosing. Implementation studies of model-based TDM in routine care are warranted.
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Affiliation(s)
- Heleen Gastmans
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium; (H.G.); (E.S.); (I.S.)
| | - Erwin Dreesen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (N.D.); (K.A.)
| | - Sebastian G. Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, 20146 Hamburg, Germany;
| | - Nada Dia
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (N.D.); (K.A.)
| | - Ellen Spreuwers
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium; (H.G.); (E.S.); (I.S.)
| | - Annabel Dompas
- Department of Information Technology, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (N.D.); (K.A.)
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Stefanie Desmet
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (S.D.); (K.L.)
- Department of Laboratory Medicine, UZ Leuven, 3000 Leuven, Belgium
| | - Katrien Lagrou
- Laboratory of Clinical Bacteriology and Mycology, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium; (S.D.); (K.L.)
- Department of Laboratory Medicine, UZ Leuven, 3000 Leuven, Belgium
| | - Willy E. Peetermans
- Laboratory of Clinical Infectious and Inflammatory Disease, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium;
- Department of General Internal Medicine, UZ Leuven, 3000 Leuven, Belgium
| | - Yves Debaveye
- Laboratory for Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000 Leuven, Belgium;
| | - Isabel Spriet
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium; (H.G.); (E.S.); (I.S.)
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (N.D.); (K.A.)
| | - Matthias Gijsen
- Pharmacy Department, UZ Leuven, 3000 Leuven, Belgium; (H.G.); (E.S.); (I.S.)
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; (E.D.); (N.D.); (K.A.)
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Wong S, Reuter SE, Jones GR, Stocker SL. Review and evaluation of vancomycin dosing guidelines for obese individuals. Expert Opin Drug Metab Toxicol 2022; 18:323-335. [PMID: 35815356 DOI: 10.1080/17425255.2022.2098106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Vancomycin dosing decisions are informed by factors such as body weight and renal function. It is important to understand the impact of obesity on vancomycin pharmacokinetics and how this may influence dosing decisions. Vancomycin dosing guidelines use varied descriptors of body weight and renal function. There is uncertainty whether current dosing guidelines result in attainment of therapeutic targets in obese individuals. AREAS COVERED Literature was explored using PubMed, Embase and Google Scholar for articles from January 1980 to July 2021 regarding obesity-driven physiological changes, their influence on vancomycin pharmacokinetics and body size descriptors and renal function calculations in vancomycin dosing. Pharmacokinetic simulations reflective of international vancomycin dosing guidelines were conducted to evaluate the ability of using total, ideal and adjusted body weight, as well as Cockcroft-Gault and CKD-EPI equations to attain an area-under-the-curve to minimum inhibitory concentration ratio (AUC24/MIC) target (400-650) in obese individuals. EXPERT OPINION Vancomycin pharmacokinetics in obese individuals remains debated. Guidelines that determine loading doses using total body weight, and maintenance doses adjusted based on renal function and adjusted body weight, may be most appropriate for obese individuals. Use of ideal body weight leads to subtherapeutic vancomycin exposure and underestimation of renal function.
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Affiliation(s)
- Sherilyn Wong
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Stephanie E Reuter
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Graham Rd Jones
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Department of Chemical Pathology and Clinical Pharmacology, SydPath, St Vincent's Hospital, Darlinghurst, Australia
| | - Sophie L Stocker
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Sydney School of Pharmacy, The University of Sydney, Sydney, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Darlinghurst, Australia
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24
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Song X, Han M. Pharmacokinetic/Pharmacodynamic Target Attainment of Vancomycin, at Three Reported Infusion Modes, for Methicillin-Resistant Staphylococcus aureus (MRSA) Bloodstream Infections in Critically Ill Patients: Focus on Novel Infusion Mode. Front Cell Infect Microbiol 2022; 12:874401. [PMID: 35873144 PMCID: PMC9300975 DOI: 10.3389/fcimb.2022.874401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe study aimed to evaluate and compare the pharmacokinetic/pharmacodynamic (PK/PD) exposure to vancomycin in the novel optimal two-step infusion (OTSI) vs. intermittent infusion (II) vs. continuous infusion (CI) mode, for MRSA bloodstream infections occurring in critical patients.MethodsWith PK/PD modeling and Monte Carlo simulations, the PK/PD exposure of 15 OTSI, 13 II, and 6 CI regimens for vancomycin, at 1, 2, 3, 4, 5, and 6 g daily dose, was evaluated. Using the Monte Carlo simulations, the vancomycin population PK parameters derived from critical patients, the PD parameter for MRSA isolates [i.e., minimum inhibitory concentration (MIC)], and the dosing parameters of these regimens were integrated into a robust mdel of vancomycin PK/PD index, defined as a ratio of the daily area under the curve (AUC0–24) to MIC (i.e., AUC0–24/MIC), to estimate the probability of target attainment (PTA) of these regimens against MRSA isolates with an MIC of 0.5, 1, 2, 4, and 8 mg/L in patients with varying renal function. The PTA at an AUC0–24/MIC ratio of >400, 400–600, and >600 was estimated. A regimen with a PTA of ≥90% at an AUC0–24/MIC ratio of 400–600, which is supposed to maximize both efficacy and safety, was considered optimal.ResultsAt the same daily dose, almost only the OTSI regimens showed a PTA of ≥90% at an AUC0–24/MIC ratio of 400–600, and this profile seems evident especially in patients with creatinine clearance (CLcr) of ≥60 ml/min and for isolates with an MIC of ≤2 mg/L. However, for patients with CLcr of <60 ml/min and for isolates with an MIC of ≥4 mg/L, the II regimens often displayed a higher or even ≥90% PTA at an AUC0–24/MIC ratio of >400 and of >600. The CI regimens frequently afforded a reduced PTA at an AUC0–24/MIC ratio of >400 and of >600, regardless of CLcr and MIC.ConclusionsThe data indicated that the OTSI regimens allowed preferred PK/PD exposure in terms of both efficacy and safety, and thus should be focused more on, especially in patients with CLcr of ≥60 ml/min and for isolates with an MIC of ≤2 mg/L.
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Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part I: focused on acute kidney injury. Expert Rev Clin Pharmacol 2022; 15:551-561. [PMID: 35734940 DOI: 10.1080/17512433.2022.2093713] [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: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article, we searched PubMed, Scopus, and Google Scholar for estimating renal function in acute kidney injury, nephrotoxicity of commonly used antibiotics, and nephrotoxin stewardship in intensive care units. EXPERT OPINION Early estimation of kidney function with an accurate method may be helpful to optimize antimicrobial treatment in critically ill patients. Different antibiotic dosing regimens may be required for patients with acute kidney injury. In many low-resource settings, therapeutic drug monitoring is not available for antibiotics. Acute kidney injury may influence treatment effectiveness and patient outcome.
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Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for Nanotechnology in Drug Delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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26
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Xu KY, Li D, Hu ZJ, Zhao CC, Bai J, Du WL. Vancomycin dosing in an obese patient with acute renal failure: A case report and review of literature. World J Clin Cases 2022; 10:6218-6226. [PMID: 35949852 PMCID: PMC9254177 DOI: 10.12998/wjcc.v10.i18.6218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/19/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vancomycin is the most commonly used drug for methicillin-resistant Staphylococcus aureus. The empirical clinical doses of vancomycin based on non-obese patients may not be optimal for obese ones.
CASE SUMMARY This study reports a case of vancomycin dosing adjustment in an obese patient (body mass index 78.4 kg/m2) with necrotizing fasciitis of the scrotum and left lower extremity accompanied with acute renal failure. Dosing adjustment was performed based on literature review and factors that influence pharmacokinetic parameters are analyzed. The results of the blood drug concentration monitoring confirmed the successful application of our dosing adjustment strategy in this obese patient. Total body weight is an important consideration for vancomycin administration in obese patients, which affects the volume of distribution and clearance of vancomycin. The alterations of pharmacokinetic parameters dictate that vancomycin should be dose-adjusted when applied to obese patients. At the same time, the pathophysiological status of patients, such as renal function, which also affects the dose adjustment of the patient, should be considered.
CONCLUSION Monitoring vancomycin blood levels in obese patients is critical to help adjust the dosing regimen to ensure that vancomycin concentrations are within the effective therapeutic range and to reduce the incidence of renal injury.
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Affiliation(s)
- Kun-Yan Xu
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Dan Li
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Zhen-Jie Hu
- Department of Intensive Care Unit, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Cong-Cong Zhao
- Department of Intensive Care Unit, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Jing Bai
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
| | - Wen-Li Du
- Department of Pharmacy, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, China
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27
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Uster DW, Wicha SG. Optimized sampling to estimate vancomycin drug exposure: Comparison of pharmacometric and equation-based approaches in a simulation-estimation study. CPT Pharmacometrics Syst Pharmacol 2022; 11:711-720. [PMID: 35259285 PMCID: PMC9197536 DOI: 10.1002/psp4.12782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/31/2022] Open
Abstract
Vancomycin dosing should be accompanied by area under the concentration‐time curve (AUC)–guided dosing using model‐informed precision dosing software according to the latest guidelines. Although a peak plus a trough sample is considered the gold standard to determine the AUC, single‐sample strategies might be more economic. Yet, optimal sampling times for AUC determination of vancomycin have not been systematically evaluated. In the present study, automated one‐ or two‐sample strategies were systematically explored to estimate the AUC with a model averaging and a model selection algorithm. Both were compared with a conventional equation‐based approach in a simulation‐estimation study mimicking a heterogenous patient population (n = 6000). The optimal single‐sample timepoints were identified between 2–6.5 h post dose, with varying bias values between −2.9% and 1.0% and an imprecision of 23.3%–24.0% across the population pharmacokinetic approaches. Adding a second sample between 4.5–6.0 h improved the predictive performance (−1.7% to 0.0% bias, 17.6%–18.6% imprecision), although the difference in the two‐sampling strategies were minor. The equation‐based approach was always positively biased and hence inferior to the population pharmacokinetic approaches. In conclusion, the approaches always preferred samples to be drawn early in the profile (<6.5 h), whereas sampling of trough concentrations resulted in a higher imprecision. Furthermore, optimal sampling during the early treatment phase could already give sufficient time to individualize the second dose, which is likely unfeasible using trough sampling.
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Affiliation(s)
- David W Uster
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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28
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Sitaruno S, Santimaleeworagun W, Pattharachayakul S, DeBacker KC, Vattanavanit V, Binyala W, Pai MP. Comparison of Race and Non-Race Based Equations for Kidney Function Estimation in Critically Ill Thai Patients for Vancomycin Dosing. J Clin Pharmacol 2022; 62:1215-1226. [PMID: 35543614 PMCID: PMC9544596 DOI: 10.1002/jcph.2070] [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: 02/25/2022] [Accepted: 05/02/2022] [Indexed: 11/12/2022]
Abstract
Empiric antibiotic dosing frequently relies on an estimate of kidney function based on age, serum creatinine (SCr), sex, and race (on occasion). New non-Race based estimated glomerular filtration rate (eGFR) equations have been published but their role to support dosing is not known. Here, we report on a population pharmacokinetic model of vancomycin that serves as a useful probe substrate of eGFR in critically ill Thai patients. Data were obtained from medical records during a 10-year period. A nonlinear mixed-effects modeling approach was conducted to estimate vancomycin parameters. Data from 208 critically ill patients (58.2% male and 36.0% septic shock) with 398 vancomycin concentrations were collected. Twenty-three covariates including 12 kidney function estimates were tested and ranked based on the model performance. The median [min, max] age, weight, and SCr was 69 [18, 97] years, 60.0 [27, 120] kg, and 1.53 [0.18, 7.15] mg/dL. The best base model was a one-compartment linear with zero-order input and proportional error model. A Thai specific eGFR equation not indexed to body surface area (BSA) model best predicted vancomycin clearance (CL). The typical value for volume of distribution and CL was 67.5 L and 1.22 L/h, respectively. A loading dose of 2000 mg followed by maintenance dose regimens based on eGFR is suggested. The Thai-GFR not indexed to BSA model best predicts vancomycin CL and dosing in the critically ill Thai population. A 5-10% absolute gain in the vancomycin probability of target attainment is expected with the use of this population specific GFR equation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sirima Sitaruno
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | | | - Sutthiporn Pattharachayakul
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Sciences, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Kenneth C DeBacker
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Veerapong Vattanavanit
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Wanrada Binyala
- Pharmacy Department, Songklanagarind Hospital, Hat Yai, Songkhla, Thailand
| | - Manjunath P Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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29
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A Machine Learning Approach to Predict Interdose Vancomycin Exposure. Pharm Res 2022; 39:721-731. [DOI: 10.1007/s11095-022-03252-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
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30
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Xiao Q, Zhang H, Wu X, Qu J, Qin L, Wang C. Augmented Renal Clearance in Severe Infections-An Important Consideration in Vancomycin Dosing: A Narrative Review. Front Pharmacol 2022; 13:835557. [PMID: 35387348 PMCID: PMC8979486 DOI: 10.3389/fphar.2022.835557] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
Vancomycin is a hydrophilic antibiotic widely used in severe infections, including bacteremia and central nervous system (CNS) infections caused by Gram-positive bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci and enterococci. Appropriate antimicrobial dosage regimens can help achieve the target exposure and improve clinical outcomes. However, vancomycin exposure in serum and cerebrospinal fluid (CSF) is challenging to predict due to rapidly changing pathophysiological processes and patient-specific factors. Vancomycin concentrations may be decreased for peripheral infections due to augmented renal clearance (ARC) and increased distribution caused by systemic inflammatory response syndrome (SIRS), increased capillary permeability, and aggressive fluid resuscitation. Additionally, few studies on vancomycin’s pharmacokinetics (PK) in CSF for CNS infections. The relationship between exposure and clinical response is unclear, challenging for adequate antimicrobial therapy. Accurate prediction of vancomycin pharmacokinetics/pharmacodynamics (PK/PD) in patients with high interindividual variation is critical to increase the likelihood of achieving therapeutic targets. In this review, we describe the interaction between ARC and vancomycin PK/PD, patient-specific factors that influence the achievement of target exposure, and recent advances in optimizing vancomycin dosing schedules for severe infective patients with ARC.
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Affiliation(s)
- Qile Xiao
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hainan Zhang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaomei Wu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, China
| | - Lixia Qin
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Chunyu Wang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
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Oommen T, Thommandram A, Palanica A, Fossat Y. A Free Open-Source Bayesian Vancomycin Dosing App for Adults: Design and Evaluation Study. JMIR Form Res 2022; 6:e30577. [PMID: 35353046 PMCID: PMC9008526 DOI: 10.2196/30577] [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: 05/20/2021] [Revised: 10/08/2021] [Accepted: 02/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background It has been suggested that Bayesian dosing apps can assist in the therapeutic drug monitoring of patients receiving vancomycin. Unfortunately, Bayesian dosing tools are often unaffordable to resource-limited hospitals. Our aim was to improve vancomycin dosing in adults. We created a free and open-source dose adjustment app, VancoCalc, which uses Bayesian inference to aid clinicians in dosing and monitoring of vancomycin. Objective The aim of this paper is to describe the design, development, usability, and evaluation of a free open-source Bayesian vancomycin dosing app, VancoCalc. Methods The app build and model fitting process were described. Previously published pharmacokinetic models were used as priors. The ability of the app to predict vancomycin concentrations was performed using a small data set comprising of 52 patients, aged 18 years and over, who received at least 1 dose of intravenous vancomycin and had at least 2 vancomycin concentrations drawn between July 2018 and January 2021 at Lakeridge Health Corporation Ontario, Canada. With these estimated and actual concentrations, median prediction error (bias), median absolute error (accuracy), and root mean square error (precision) were calculated to evaluate the accuracy of the Bayesian estimated pharmacokinetic parameters. Results A total of 52 unique patients’ initial vancomycin concentrations were used to predict subsequent concentration; 104 total vancomycin concentrations were assessed. The median prediction error was –0.600 ug/mL (IQR –3.06, 2.95), the median absolute error was 3.05 ug/mL (IQR 1.44, 4.50), and the root mean square error was 5.34. Conclusions We described a free, open-source Bayesian vancomycin dosing calculator based on revisions of currently available calculators. Based on this small retrospective preliminary sample of patients, the app offers reasonable accuracy and bias, which may be used in everyday practice. By offering this free, open-source app, further prospective validation could be implemented in the near future.
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Affiliation(s)
| | | | - Adam Palanica
- Klick Applied Sciences, Klick Health, Klick Inc, Toronto, ON, Canada
| | - Yan Fossat
- Klick Applied Sciences, Klick Health, Klick Inc, Toronto, ON, Canada
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The Role of Surface Enhanced Raman Scattering for Therapeutic Drug Monitoring of Antimicrobial Agents. CHEMOSENSORS 2022. [DOI: 10.3390/chemosensors10040128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The rapid quantification of antimicrobial agents is important for therapeutic drug monitoring (TDM), enabling personalized dosing schemes in critically ill patients. Highly sophisticated TDM technology is becoming available, but its implementation in hospitals is still limited. Among the various proposed techniques, surface-enhanced Raman scattering (SERS) stands out as one of the more interesting due to its extremely high sensitivity, rapidity, and fingerprinting capabilities. Here, we present a comprehensive review of various SERS-based novel approaches applied for direct and indirect detection and quantification of antibiotic, antifungal, and antituberculosis drugs in different matrices, particularly focusing on the challenges for successful exploitation of this technique in the development of assays for point-of-care tests.
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33
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Heus A, Uster DW, Grootaert V, Vermeulen N, Somers A, In't Veld DH, Wicha SG, De Cock PA. Model-informed precision dosing of vancomycin via continuous infusion: a clinical fit-for-purpose evaluation of published PK models. Int J Antimicrob Agents 2022; 59:106579. [PMID: 35341931 DOI: 10.1016/j.ijantimicag.2022.106579] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/08/2022] [Accepted: 03/20/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Model-informed precision dosing (MIPD) is an innovative approach used to guide bedside vancomycin dosing. The use of Bayesian software requires suitable and externally validated population pharmacokinetic (popPK) models. OBJECTIVES Therefore, we aimed to identify suitable popPK models for a priori prediction and a posteriori forecasting of vancomycin in continuous infusion. Additionally, a model averaging (MAA) and a model selection approach (MSA) were compared with the identified popPK models. METHODS . Clinical PK data were retrospectively collected from patients receiving continuous vancomycin therapy and admitted to a general ward of three large Belgian hospitals. The predictive performance of the popPK models, identified in a systematic literature search, as well as the MAA/MSA was evaluated for the a priori and a posteriori scenarios using bias, root mean square errors, normalized prediction distribution errors and visual predictive checks. RESULTS The predictive performance of 23 popPK models was evaluated based on clinical data from 169 patients and 923 therapeutic drug monitoring samples. Overall, the best predictive performance was found using the Okada model (bias < -0.1 mg/L), followed by the Colin model. The MAA/MSA predicted with a constantly high precision and low inaccuracy and were clinically acceptable in the Bayesian forecasting. CONCLUSION This study identified the two-compartmental models of Okada et al. and Colin et al. as most suitable for non-ICU patients to forecast individual exposure profiles after continuous vancomycin infusion. The MAA/MSA performed equally good as the individual popPK models. Both approaches could therefore be used in clinical practice to guide dosing decisions.
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Affiliation(s)
- Astrid Heus
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium; Department of Pharmacy, General Hospital Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| | - David W Uster
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Veerle Grootaert
- Department of Pharmacy, General Hospital Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| | - Nele Vermeulen
- Department of Pharmacy, General hospital OLV Aalst, Aalst, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Diana Huis In't Veld
- Department of Internal Medicine and Infectious Diseases Ghent University Hospital, Ghent, Belgium
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Pieter A De Cock
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium; Department of Paediatric Intensive Care, Ghent University Hospital, Ghent, Belgium; Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.
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Maung NH, Methaneethorn J, Wattanavijitkul T, Sriboonruang T. Comparison of area under the curve for vancomycin from one- and two-compartment models using sparse data. Eur J Hosp Pharm 2022; 29:e57-e62. [PMID: 34285111 PMCID: PMC8899690 DOI: 10.1136/ejhpharm-2020-002637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 06/15/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Vancomycin pharmacokinetics have been described by both one- and two-compartment models. One-compartment models are widely used to predict the area under the curve (AUC), a useful parameter for determining the efficacy and safety of vancomycin, based on sparse data collected during therapeutic drug monitoring. It is uncertain whether AUCs from one-compartment models with sparsely sampled data can sufficiently represent the true AUC. This study aimed to compare AUC estimates from one- and two-compartment models using sparse data. The reliability of AUCs from models constructed with trough-only data was also assessed. METHODS A previously published robust model was used to simulate vancomycin concentration points at 15 min intervals in 100 patients. From these simulated data, the reference AUC (AUCref) was calculated and two depleted dataset versions (trough-only and peak-trough datasets) were also created. One- and two-compartment models were built from the depleted datasets with the use of NONMEM. Vancomycin 24-hour AUC was calculated from concentration-time profiles of each model by a linear trapezoidal formula at three different time periods: 0-24 hours (AUC0-24), 24-48 hours (AUC24-48) and 0-48 hours (AUCavg). The deviation of each of the AUCs from the AUCref was examined to assess the AUC predictability of models from sparse data. The difference in AUCs between one- and two-compartment models was analysed from statistical and clinical perspectives. RESULTS When assessing the deviation of each AUC from the AUCref, the one-compartment model from both peak-trough and trough-only data could adequately represent the true AUC with no statistically significant differences. Two-compartment model from peak-trough data also provided similar AUC estimates with the AUCref. However, AUCs from the two-compartment model with trough-only data did not adequately represent the true AUC, with significant differences of 25.16% for AUC0-24, 15.92% for AUC24-48 and 19.45% for AUCavg. CONCLUSION Regardless of statistically significant differences between AUCs from one- and two-compartment models, the level of difference was acceptable from the clinical perspective, being <17% in models from peak-trough data. Therefore, both one- and two-compartment models with sparse data having at least a pair of peak-trough data per patient could be reliable for predicting AUC. Furthermore, AUCs of the one-compartment model from trough-only data did not show a significant difference from the AUCref. Hence, one-compartment models developed from trough-only data could be useful for predicting AUC when models with rich data are not available for the intended population. However, it is suggested that the use of the two-compartment model built from trough-only data should be avoided.
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Affiliation(s)
- Nyein Hsu Maung
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Janthima Methaneethorn
- Department of Pharmacy Practice, Faculty of Pharmaceutical sciences, Naresuan University, Phitsanulok, Thailand
| | - Thitima Wattanavijitkul
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Tatta Sriboonruang
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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Gorham J, Taccone FS, Hites M. Ensuring target concentrations of antibiotics in critically ill patients through dose adjustment. Expert Opin Drug Metab Toxicol 2022; 18:177-187. [PMID: 35311440 DOI: 10.1080/17425255.2022.2056012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Antibiotics are commonly prescribed in critical care, and given the large variability of pharmacokinetic (PK) parameters in these patients, drug PK frequently varies during therapy with the risk of either treatment failure or toxicity. Therefore, adequate antibiotic dosing in critically ill patients is very important. AREAS COVERED This review provides an overview of the basic principles of PK and pharmacodynamics of antibiotics and the main patient and pathogen characteristics that may affect the dosage of antibiotics and different approaches to adjust doses. EXPERT OPINION Dose adjustment should be done for aminoglycosides and glycopeptides based on daily drug concentration monitoring. For glycopeptides, in particular vancomycin, the residual concentration (Cres) should be assessed daily. For beta-lactam antibiotics, a loading dose should be administered, followed by three different possible approaches, as TDM is rarely available in most centers: 1) antibiotic regimens should be adapted according to renal function and other risk factors; 2) nomograms or software can be used to calculate daily dosing; 3) TDM should be performed 24-48 h after the initiation of treatment; however, the results are required within 24 hours to appropriately adjust dosage regimens. Drug dosing should be reduced or increased according to the TDM results.
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Affiliation(s)
- Julie Gorham
- Department of intensive care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of intensive care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Maya Hites
- Clinic of Infectious diseases, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Sistanizad M, Hassanpour R, Pourheidar E. Are Antibiotics Appropriately Dosed in Critically Ill Patients with Augmented Renal Clearance? A Narrative Review. Int J Clin Pract 2022; 2022:1867674. [PMID: 35685541 PMCID: PMC9159163 DOI: 10.1155/2022/1867674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/17/2021] [Accepted: 12/03/2021] [Indexed: 11/18/2022] Open
Abstract
AIMS Augmented renal clearance (ARC), which is commonly defined as increased renal clearance above 130 ml/min/1.73 m2, is a common phenomenon among critically ill patients. The increased elimination rate of drugs through the kidneys in patients with ARC can increase the risk of treatment failure due to the exposure to subtherapeutic serum concentrations of medications and affect the optimal management of infections, length of hospital stay, and outcomes. The main goal of this review article is to summarize the recommendations for appropriate dosing of antibiotics in patients with ARC. METHODS This article is a narrative review of the articles that evaluated different dosing regimens of antibiotics in patients with ARC. The keywords "Augmented Renal Clearance," "Critically ill patients," "Drug dosing," "Serum concentration," "Beta-lactams," "Meropenem," "Imipenem," "Glycopeptide," "Vancomycin," "Teicoplanin," "Linezolid," "Colistin," "Aminoglycosides," "Amikacin," "Gentamycin," "Fluoroquinolones," "Ciprofloxacin," and "Levofloxacin" were searched in Scopus, Medline, PubMed, and Google Scholar databases, and pediatric, nonhuman, and non-English studies were excluded. RESULTS PK properties of antibiotics including lipophilicity or hydrophilicity, protein binding, the volume of distribution, and elimination rate that affect drug concentration should be considered along with PD parameters for drug dosing in critically ill patients with ARC. CONCLUSION This review recommends a dosing protocol for some antibiotics to help the appropriate dosing of antibiotics in ARC and decrease the risk of subtherapeutic exposure that may be observed while receiving conventional dosing regimens in critically ill patients with ARC.
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Affiliation(s)
- Mohammad Sistanizad
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rezvan Hassanpour
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Pourheidar
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 923] [Impact Index Per Article: 307.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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38
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Population Pharmacokinetic Modeling and Dose Optimization of Vancomycin in Chinese Patients with Augmented Renal Clearance. Antibiotics (Basel) 2021; 10:antibiotics10101238. [PMID: 34680818 PMCID: PMC8532702 DOI: 10.3390/antibiotics10101238] [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: 08/28/2021] [Revised: 09/30/2021] [Accepted: 10/08/2021] [Indexed: 12/25/2022] Open
Abstract
Patients with augmented renal clearance (ARC) have been described as having low vancomycin concentration. However, the pharmacokinetic model that best describes vancomycin in patients with ARC has not been clarified. The purpose of this study is to determine the pharmacokinetic of vancomycin in Chinese adults and the recommend dosage for patients with different renal function, including patients with ARC. We retrospectively collected 424 vancomycin serum concentrations from 209 Chinese patients and performed a population pharmacokinetic model using NONMEM 7.4.4. The final model indicated that the clearance rate of vancomycin increased together with the creatinine clearance, and exhibited a nearly saturated curve at higher creatinine clearance. The estimated clearance of vancomycin was between 3.46 and 5.58 L/h in patients with ARC, with 5.58 being the maximum theoretical value. The central volume of distribution increased by more than three times in patients admitted to Intensive Care Unit. Monte Carlo simulations were conducted to explore the probability of reaching the target therapeutic range (24-h area under the curve: 400–650 mg·h/L, trough concentration: 10–20 mg/L) when various dose regimens were administered. The simulations indicated that dose should increase together with the creatinine clearance until 180 mL/min. These findings may contribute to improving the efficacy and safety of vancomycin in patients with ARC.
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1507] [Impact Index Per Article: 502.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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Gilliot S, Boukhris MR, Masse M, Storme L, Décaudin B, Odou P, Le Duc K. Case report: risk of skin necrosis related to injectable vancomycin in critically ill newborn infants. BMC Pediatr 2021; 21:343. [PMID: 34388991 PMCID: PMC8361791 DOI: 10.1186/s12887-021-02824-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background Vancomycin is commonly used as part of empiric antibiotic therapy in the preterm infants who develop signs and symptoms of infection. Although skin necrosis has been noted to occur following injection of vancomycin into a peripheral vein in an adult patient, this complication has not been previously described in a preterm infant. Case presentation We report the case of a very low birthweight male infant born at 30 weeks gestational age who developed skin necrosis, most likely as a complication of vancomycin administration via a peripheral venous catheter. The immature skin and endothelial cells of this preterm infant may have increased the risk of drugs related venous and skin toxicity. In this case, assumption of a cumulative toxicity with other drugs administered concomitantly via the same catheter can’t be excluded. Conclusions To prevent the risk of skin damage, we advocate that in newborn infants, the administration of vancomycin should be limited to a concentration of < 2.5 mg/mL via a peripheral intravenous catheter if a central venous catheter is not available.
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Affiliation(s)
- Sixtine Gilliot
- Univ. Lille, CHU Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France.,Institut de Pharmacie, CHU Lille, 59000, Lille, France
| | - Mohamed Riadh Boukhris
- Univ. Lille, CHU Lille, ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France. .,Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000, Lille, France. .,Institute/University/Hospital : CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme, mère et Nouveau-né, Avenue Eugène Avinée, 59120, Lille, Loos, France.
| | - Morgane Masse
- Univ. Lille, CHU Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France.,Institut de Pharmacie, CHU Lille, 59000, Lille, France
| | - Laurent Storme
- Univ. Lille, CHU Lille, ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France.,Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000, Lille, France
| | - Bertrand Décaudin
- Univ. Lille, CHU Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France.,Institut de Pharmacie, CHU Lille, 59000, Lille, France
| | - Pascal Odou
- Univ. Lille, CHU Lille, ULR 7365 - GRITA - Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000, Lille, France.,Institut de Pharmacie, CHU Lille, 59000, Lille, France
| | - Kevin Le Duc
- Univ. Lille, CHU Lille, ULR 2694- METRICS: Evaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France.,Department of Neonatology, Jeanne de Flandre Hospital, University Hospital of Lille, F-59000, Lille, France
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Song X, Zeng M, Wu Y, Pan Y. Competence Mining of Vancomycin (VAN) in the Management of Infections Due to Bacterial Strains With High VAN Minimum Inhibitory Concentrations (MICs): A Novel Dosing Strategy Based on Pharmacokinetic/Pharmacodynamic Modeling. Front Microbiol 2021; 12:649757. [PMID: 33967986 PMCID: PMC8100448 DOI: 10.3389/fmicb.2021.649757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/30/2021] [Indexed: 11/13/2022] Open
Abstract
The increasing emergence of bacterial strains with high VAN MICs (BSH–VAN–M), such as Enterococcus faecalis, Enterococcus faecium, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus bovis, results in growing concern that VAN is not effective against these isolates. Due to the limited data on VAN against BSH–VAN–M and the application limits of drugs currently considered to be effective for BSH–VAN–M, exploration of “new usages for old drugs” is reasonable to improve and maximize the efficacy of existing antibiotics. This study aimed to construct a novel dosing strategy to mine the competence of VAN in the management of BSH–VAN–M infections. Herein, we optimized the traditional intermittent i.v. infusion (TIII) method to create an optimal two-step infusion (OTSI). With pharmacokinetic (PK)/pharmacodynamic (PD) modeling at the targeted ratio of the daily area under the concentration-time curve (AUC0–24) to the minimum inhibitory concentration (MIC) (AUC0–24/MIC) of 400, we used Monte Carlo simulations to evaluate the efficacy of 25 VAN regimens (including 15 OTSI regimens and 10 TIII regimens with daily doses of up to 6 g) to treat pneumonia, meningitis, sternal osteomyelitis, mastitis, pleuritis, bacteremia, and bacterial pericarditis resulting from isolates with MICs of ≤64 mg/L and to the current E. faecalis, E. faecium, S. aureus, S. epidermidis, and S. bovis populations with a pooled MIC distribution. Our data indicated that 4 g/day VAN, with an OTSI but not a TIII, for mastitis, pleuritis, bacteremia, and bacterial pericarditis due to isolates with MICs of ≤4 mg/L or to the current E. faecalis, S. aureus, S. epidermidis, and S. bovis populations achieved the desired PK/PD exposure at the AUC0–24/MIC target of 400. This study suggests the superiority and feasibility of OTSI relative to TIII for the competence mining of VAN against BSH–VAN–M from the perspective of PK/PD and provides a new resource for understanding how PK/PD modeling shapes the performance of VAN to meet the growing challenges of BSH–VAN–M infections.
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Affiliation(s)
- Xiangqing Song
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Meizi Zeng
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yi Wu
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Yong Pan
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
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42
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Huang X, Yu Z, Wei X, Shi J, Wang Y, Wang Z, Chen J, Bu S, Li L, Gao F, Zhang J, Xu A. Prediction of vancomycin dose on high-dimensional data using machine learning techniques. Expert Rev Clin Pharmacol 2021; 14:761-771. [PMID: 33835879 DOI: 10.1080/17512433.2021.1911642] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Despite therapeutic vancomycin is regularly monitored, its dose requirements vary considerably between individuals. Various innovative vancomycin dosing strategies have been developed for dose optimization; however, the utilization of individual factors and extensibility is insufficient. We aimed to develop an optimal dosing algorithm for vancomycin based on the high-dimensional data using the proposed variable engineering and machine-learning methods. METHODS This study proposed a variable engineering process that automatically generates second-order variable interactions. We performed an initial examination of independent variables and interactive variables using eXtreme Gradient Boosting. The vancomycin dose prediction model was established based on the derived variables. RESULTS Based on the evaluation of the model performance in the validation cohort, our algorithm accounted for 67.5% of variations in the vancomycin doses. Subgroup analysis showed better performance in patients with medium and high body weight (with the ideal predictive percentage of 72.7% and 73.7%), and low and medium levels of serum creatinine (with the ideal predictive percentage of 77.8% and 73.1%) than in other groups. CONCLUSION The new vancomycin dose prediction model is potentially useful for patients whose population profiles are similar to those of our patients and yielded desired reference of clinical indicators with specific breakpoints.
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Affiliation(s)
- Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ze Yu
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Xin Wei
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Junfeng Shi
- Department of Nephrology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Wang
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Zeyuan Wang
- Beijing Medicinovo Technology Co. Ltd., Beijing, China.,School of Computer Science, The University of Sydney, Sydney, Australia
| | - Jihui Chen
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shuhong Bu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lixia Li
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fei Gao
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Jian Zhang
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ajing Xu
- Department of Pharmacy, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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43
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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: 594] [Impact Index Per Article: 198.0] [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
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Diamantis S, Dawudi Y, Cassard B, Longuet P, Lesprit P, Gauzit R. Home intravenous antibiotherapy and the proper use of elastomeric pumps: Systematic review of the literature and proposals for improved use. Infect Dis Now 2021; 51:39-49. [PMID: 33576336 DOI: 10.1016/j.medmal.2020.10.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 04/28/2020] [Accepted: 10/15/2020] [Indexed: 11/30/2022]
Abstract
Over several decades, the economic situation and consideration of patient quality of life have been responsible for increased outpatient treatment. It is in this context that outpatient antimicrobial treatment (OPAT) has rapidly developed. The availability of elastomeric infusion pumps has permitted prolonged or continuous antibiotic administration by dint of a mechanical device necessitating neither gravity nor a source of electricity. In numerous situations, its utilization optimizes administration of time-dependent antibiotics while freeing the patient from the constraints associated with infusion by gravity, volumetric pump or electrical syringe pump and, more often than not, limiting the number of nurse interventions to one or two a day. That much said, the installation of these pumps, which is not systematically justified, entails markedly increased OPAT costs and is liable to expose the patient to a risk of therapeutic failure or adverse effects due to the instability of the molecules utilized in a non-controlled environment, instability that necessitates close monitoring of their use. More precisely, a prescriber must take into consideration the stability parameters of each molecule (infusion duration, concentration following dilution, nature of the diluent and pump temperature). The objective of this work is to evaluate the different means of utilization of elastomeric infusion pumps in intravenous antibiotic administration outside of hospital. Following a review of the literature, we will present a tool for optimized antibiotic prescription, in a town setting by means of an infusion device.
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Affiliation(s)
- S Diamantis
- Service des maladies infectieuses et tropicales, groupe hospitalier Sud Île-de-France, 270, boulevard Marc-Jacquet, 77000 Melun, France.
| | - Y Dawudi
- Service des maladies infectieuses et tropicales, groupe hospitalier Sud Île-de-France, 270, boulevard Marc-Jacquet, 77000 Melun, France
| | - B Cassard
- Service de pharmacie hospitalière, groupe hospitalier Sud Île-de-France, Melun, France
| | - P Longuet
- Équipe mobile d'antibiothérapie, centre hospitalier Victor-Dupouy, Argenteuil, France
| | - P Lesprit
- Unité transversale d'hygiène et d'infectiologie, service de biologie clinique, hôpital Foch, Suresnes, France
| | - R Gauzit
- Équipe mobile d'infectiologie, réanimation Ollier, hôpital Cochin AP-HP, Paris, France
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Godi I, Lorenzin A, De Rosa S, Golino G, Knust M, Gaspar A, Sandini A, Fiorin F, de Cal M, Navalesi P, Ronco C. Vancomycin Adsorption During in vitro Model of Hemoperfusion with HA380 Cartridge. Nephron Clin Pract 2021; 145:157-163. [PMID: 33567447 DOI: 10.1159/000513122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION A critical point for using blood purification during sepsis may be the potential interaction with antimicrobial therapy, the mainstay of sepsis treatment. The aim of our study was to investigate the vancomycin removal during hemoperfusion (HP) using HA380 cartridge. METHODS This is an experimental study, in which 500 mL of solution was circulated in a closed-circuit (blood flow of 250 mL/min) simulating HP ran using HA380. Vancomycin was added to reach a through concentration or a very high concentration to evaluate the removal ratio (RR) during 120 min of HP. Comparison between blood-crystalloid solution and balanced solution was performed by using Kruskal-Wallis test. The kinetics of vancomycin removal and the adsorption isotherm were evaluated. RESULTS We found a complete removal of vancomycin at baseline through concentration of 23.0 ± 7.4 mg/L. Using extremely high concentration (baseline 777.0 ± 62.2 mg/L), RR was 90.1 ± 0.6% at 5 min and 99.2 ± 0.6% at 120 min. No difference in terms of RR was found between blood-crystalloid mixture and balanced solution. The kinetics of the vancomycin reduction followed an exponential decay. Repeated boluses (total amount of 2,000 mg) resulted in cumulative adsorption of 1,919.4 mg with RR of 96.6 ± 1.4%, regardless of the amount injected (100 vs. 500 mg). Vancomycin adsorption onto HA380 followed the Langmuir isotherm model. CONCLUSIONS A considerable amount of vancomycin was rapidly removed during in vitro HP with HA380. Clinical studies are needed to determine whether this may lead to underdosing. Drug therapeutic monitoring is highly recommended when using HA380 for blood purification in patients receiving vancomycin.
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Affiliation(s)
- Ilaria Godi
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy, .,International renal Research Institute of Vicenza, Vicenza, Italy,
| | - Anna Lorenzin
- International renal Research Institute of Vicenza, Vicenza, Italy
| | - Silvia De Rosa
- International renal Research Institute of Vicenza, Vicenza, Italy.,Department of Anesthesia and Intensive Care, San Bortolo Hospital, Vicenza, Italy
| | - Gianlorenzo Golino
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy.,International renal Research Institute of Vicenza, Vicenza, Italy
| | - Maira Knust
- International renal Research Institute of Vicenza, Vicenza, Italy
| | - Ana Gaspar
- International renal Research Institute of Vicenza, Vicenza, Italy
| | - Alessandra Sandini
- Department of Transfusional Medicine, San Bortolo Hospital, Vicenza, Italy
| | - Francesco Fiorin
- Department of Transfusional Medicine, San Bortolo Hospital, Vicenza, Italy
| | - Massimo de Cal
- International renal Research Institute of Vicenza, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Paolo Navalesi
- Department of Medicine - DIMED, Section of Anesthesiology and Intensive Care, University of Padova, Padova, Italy
| | - Claudio Ronco
- International renal Research Institute of Vicenza, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy.,Department of Medicine - DIMED, University of Padova, Padova, Italy
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Abstract
Introduction: Nosocomial pneumonia unfortunately remains a frequent event for which appropriate antibiotic treatment is central to improving outcomes. Physicians must choose an early and appropriate empirical treatment, basing their decision on the safety profile and possible side effects. Areas covered: In this review, we analyzed the safety profiles of the most common antimicrobials for treating nosocomial pneumonia. Beta-lactams are used most often for these infections, with a high percentage (6% to 25%) of patients reporting allergy or hypersensitivity reactions; however, exhaustive evaluation is key because it seems possible to de-label as many as 90% by proper assessment. Combinations including a beta-lactam are recommended in patients with risk factors for drug-resistant microorganisms and septic shock. Although aminoglycosides are safe for 3-5 days of therapy, renal function should be monitored. Fluoroquinolones must also be used with care given the risk of collagen degradation and cardiovascular events, mainly aneurysm or aortic dissection. Linezolid or vancomycin are both viable for the treatment of methicillin-resistant Staphylococcus aureus, but linezolid seems to be the superior option. Antibiotic stewardships programs must be developed for each center. Expert opinion: Choosing the most appropriate antimicrobial based on information from national and international guidelines, local microbiology data, and stewardship programs may reduce the use of broad-spectrum antibiotics. Daily assessment for the emergence of adverse events related to antimicrobial use is essential.
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Jalusic KO, Hempel G, Arnemann PH, Spiekermann C, Kampmeier TG, Ertmer C, Gastine S, Hessler M. Population pharmacokinetics of vancomycin in patients with external ventricular drain-associated ventriculitis. Br J Clin Pharmacol 2020; 87:2502-2510. [PMID: 33202067 DOI: 10.1111/bcp.14657] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To determine the distribution of vancomycin into the cerebrospinal fluid (CSF) in patients with external ventricular drain (EVD)-associated ventriculitis, the pharmacokinetics of vancomycin were evaluated and covariate relationships explored. METHODS For the population pharmacokinetic model patients were recruited in a neurocritical care unit at the University Hospital of Muenster in the period between January 2014 and June 2015. All patients had a clinical evidence of EVD-associated ventriculitis. Population pharmacokinetic analysis of vancomycin was performed using NONMEM. RESULTS A total of 184 blood and 133 CSF samples were collected from 29 patients. The final population pharmacokinetic model is a three-compartment model with linear elimination. Creatinine clearance (ClCr ) and CSF-lactate were detected as significant covariates, showing that the total vancomycin plasma clearance (Cl) depends on ClCr and furthermore the clearance (Cldif ) between the central and CSF compartment correlates with CSF lactate concentration. Based on the final model, the following values were estimated by NONMEM: Cl = 5.15 L/h, Q (intercompartmental clearance) = 3.31 L/h, Cldif = 0.0031 L/h, Vcentral = 42.1 L, VCSF = 0.32 L and the value of Vperipheral was fixed to 86.2 L. With the developed pharmacokinetic model, area under the curve (AUC) values as well as CSF trough levels were simulated. CONCLUSION Based on our analysis, the dosing of vancomycin should be referred to the degree of inflammation (derived from the CSF lactate concentration) and renal function (derived from ClCr ).
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Affiliation(s)
- Kris Oliver Jalusic
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany.,Institute of Epidemiology and Social Medicine, Faculty of Medicine, University of Muenster, Muenster, Germany
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany
| | - Philip-Helge Arnemann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Christina Spiekermann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Tim-Gerald Kampmeier
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Christian Ertmer
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Silke Gastine
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, Muenster, Germany.,Infection, Immunity & Inflammation Research & Teaching Department, GOS Institute of Child Health, University College London, London, UK
| | - Michael Hessler
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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Pongchaidecha M, Changpradub D, Bannalung K, Seejuntra K, Thongmee S, Unnual A, Santimaleeworagun W. Vancomycin Area under the Curve and Pharmacokinetic Parameters during the First 24 Hours of Treatment in Critically Ill Patients using Bayesian Forecasting. Infect Chemother 2020; 52:573-582. [PMID: 33263245 PMCID: PMC7779987 DOI: 10.3947/ic.2020.52.4.573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/18/2020] [Indexed: 12/29/2022] Open
Abstract
Background Currently, the achievement of the target area under the curve (AUC)/minimum inhibitory concentration ratio during the first 24 - 48 h of treatment is associated with reduced 30-day mortality and greater microbiological eradication in patients with methicillin-resistant Staphylococcus aureus bacteremia. This study aimed to determine the AUC and pharmacokinetic parameters on the first day of vancomycin administration based on the Bayesian theorem to optimize the dosing regimen in critically ill patients. Materials and Methods This retrospective study included participants meeting the following criteria: 1) ≥18 years old; 2) receipt of at least one dose of vancomycin; 3) measurement of 2 vancomycin serum concentrations during the first 24 h of treatment; and 4) an intensive care unit admission, mechanical ventilator use, or an Acute Physiology and Chronic Health Evaluation II score >15 points. The AUC on day 1 of treatment and the estimated vancomycin pharmacokinetic parameters were measured using PrecisePK software based on the Bayesian theorem. Results We obtained 132 vancomycin concentrations from 66 patients. The vancomycin pharmacokinetic parameters were as follows: AUC0-24, 571.09 (± standard deviation [SD] 188.62) mg/L·h; clearance (CL), 2.97 (± SD 1.81) L/h; volume of distribution (Vd), 50.60 (± SD 13.91) L; elimination rate constant, 0.062 (± SD 0.039) h−1; and half-life, 18.19 (± SD 15.96) h. Focusing on the vancomycin loading dose, AUC0-24 400 - 600 was achieved in 41.7, 46.1, 44.4, and 26.3% of patients with loading doses of <20, 20 – 24.9, 25 – 30, and >30 mg/kg, respectively. Whereas AUC0-24 ≥521 was achieved in 50, 50, 77.8, and 84.2% of patients with loading doses of <20, 20 – 24.9, 25 – 30, and >30 mg/kg, respectively. The CL of vancomycin was correlated with creatinine CL, whereas the Vd of vancomycin was significantly correlated with age and body weight. Conclusion This study revealed that the higher Vd and CL values on the first day of vancomycin therapy were found in critically ill patients. Additionally, a higher vancomycin loading dose (25 – 30 mg/kg) might be required to achieve target of AUC0-24 during early phase of administration for critically ill patients.
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Affiliation(s)
- Manat Pongchaidecha
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Dhitiwat Changpradub
- Division of Infectious Diseases, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Kanjana Bannalung
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Kajeewan Seejuntra
- Department of Pharmacy, Ramathibodi Chakri Naruebodindra Hospital, Samutprakarn, Thailand
| | | | - Aminta Unnual
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand
| | - Wichai Santimaleeworagun
- Department of Pharmacy, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand.,Antibiotic Optimization and Patient Care Project by Pharmaceutical Initiative for Resistant Bacteria and Infectious Diseases Working Group, Faculty of Pharmacy, Silpakorn University, Nakhon Pathom, Thailand.
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49
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Perin N, Roger C, Marin G, Molinari N, Evrard A, Lavigne JP, Barbar S, Claret PG, Boutin C, Muller L, Lipman J, Lefrant JY, Jaber S, Roberts JA. Vancomycin Serum Concentration after 48 h of Administration: A 3-Years Survey in an Intensive Care Unit. Antibiotics (Basel) 2020; 9:antibiotics9110793. [PMID: 33182613 PMCID: PMC7698174 DOI: 10.3390/antibiotics9110793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022] Open
Abstract
The present study assessed the proportion of intensive care unit (ICU) patients who had a vancomycin serum concentration between 20 and 25 mg/L after 24–48 h of intravenous vancomycin administration. From 2016 to 2018, adult ICU patients with vancomycin continuous infusion (CI) for any indication were included. The primary outcome was the proportion of patients with a first-available vancomycin serum concentration between 20–25 mg/L at 24 h (D2) or 48 h (D3). Of 3894 admitted ICU patients, 179 were included. A median loading dose of 15.6 (interquartile range (IQR) = (12.5–20.8) mg/kg) was given in 151/179 patients (84%). The median daily doses of vancomycin infusion for D1 and D2 were 2000 [(IQR (1600–2000)) and 2000 (IQR (2000–2500)) mg/d], respectively. The median duration of treatment was 4 (2–7) days. At D2 or D3, the median value of first serum vancomycin concentration was 19.8 (IQR (16.0–25.1)) with serum vancomycin concentration between 20–25 mg/L reported in 43 patients (24%). Time spent in the ICU before vancomycin initiation was the only risk factor of non-therapeutic concentration at D2 or D3. Acute kidney injury occurred significantly more when vancomycin concentration was supra therapeutic at D2 or D3. At D28, 44 (26%) patients had died. These results emphasize the need of appropriate loading dose and regular monitoring to improve vancomycin efficacy and avoid renal toxicity.
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Affiliation(s)
- Nicolas Perin
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- Correspondence:
| | - Claire Roger
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Grégory Marin
- IMAG, CNRS, Université de Montpellier, Department of Statistics, CHU Montpellier, 34295 Montpellier, France; (G.M.); (N.M.)
| | - Nicolas Molinari
- IMAG, CNRS, Université de Montpellier, Department of Statistics, CHU Montpellier, 34295 Montpellier, France; (G.M.); (N.M.)
| | - Alexandre Evrard
- Laboratoire de Biochimie, Centre Hospitalier Universitaire (CHU) de Nîmes, Hôpital Carémeau, 30029 Nîmes, France;
| | - Jean-Philippe Lavigne
- VBMI, INSERM U1047, Université de Montpellier, Laboratoire de Microbiologie, CHU de Nîmes, 30029 Nîmes, France;
| | - Saber Barbar
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Pierre Géraud Claret
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Caroline Boutin
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Laurent Muller
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Jeffrey Lipman
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- VBMI, INSERM U1047, Université de Montpellier, Laboratoire de Microbiologie, CHU de Nîmes, 30029 Nîmes, France;
- Department of Intensive Care Medicine, Royal Brisbane and Womens’ Hospital, Brisbane 4029, QLD, Australia
- UQ Centre for Clinical Research, The University of Queensland, Brisbane 4029, QLD, Australia
| | - Jean-Yves Lefrant
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Samir Jaber
- Département d’Anesthésie Réanimation B, Saint Eloi ICU, Montpellier University Hospital, 34295 Montpellier, France;
| | - Jason A. Roberts
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- UQ Centre for Clinical Research, The University of Queensland, Brisbane 4029, QLD, Australia
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane 4029, QLD, Australia
- Pharmacy Department, Royal Brisbane and Womens’ Hospital, Brisbane 4029, QLD, Australia
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50
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Uster DW, Stocker SL, Carland JE, Brett J, Marriott DJE, Day RO, Wicha SG. A Model Averaging/Selection Approach Improves the Predictive Performance of Model-Informed Precision Dosing: Vancomycin as a Case Study. Clin Pharmacol Ther 2020; 109:175-183. [PMID: 32996120 DOI: 10.1002/cpt.2065] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/12/2020] [Indexed: 11/10/2022]
Abstract
Many important drugs exhibit substantial variability in pharmacokinetics and pharmacodynamics leading to a loss of the desired clinical outcomes or significant adverse effects. Forecasting drug exposures using pharmacometric models can improve individual target attainment when compared with conventional therapeutic drug monitoring (TDM). However, selecting the "correct" model for this model-informed precision dosing (MIPD) is challenging. We derived and evaluated a model selection algorithm (MSA) and a model averaging algorithm (MAA), which automates model selection and finds the best model or combination of models for each patient using vancomycin as a case study, and implemented both algorithms in the MIPD software "TDMx." The predictive performance (based on accuracy and precision) of the two algorithms was assessed in (i) a simulation study of six distinct populations and (ii) a clinical dataset of 180 patients undergoing TDM during vancomycin treatment and compared with the performance obtained using a single model. Throughout the six virtual populations the MSA and MAA (imprecision: 9.9-24.2%, inaccuracy: less than ± 8.2%) displayed more accurate predictions than the single models (imprecision: 8.9-51.1%; inaccuracy: up to 28.9%). In the clinical dataset, the predictive performance of the single models applying at least one plasma concentration varied substantially (imprecision: 28-62%, inaccuracy: -16 to 25%), whereas the MSA or MAA utilizing these models simultaneously resulted in unbiased and precise predictions (imprecision: 29% and 30%, inaccuracy: -5% and 0%, respectively). MSA and MAA approaches implemented in TDMx might thereby lower the burden of fit-for-purpose validation of individual models and streamline MIPD.
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Affiliation(s)
- David W Uster
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sophie L Stocker
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jane E Carland
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jonathan Brett
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Deborah J E Marriott
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Department of Clinical Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, New South Wales, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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