51
|
Lulic-Botica M, Sheer T, Edwards D, Thomas RL, Natarajan G. Impact of small-for-gestational age (SGA) status on gentamicin pharmacokinetics in neonates. J Clin Pharmacol 2013; 54:39-45. [DOI: 10.1002/jcph.190] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 09/17/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Mirjana Lulic-Botica
- Department of Pharmacy; Hutzel Women's Hospital; Detroit MI USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences; Wayne State University; Detroit MI USA
| | - Terri Sheer
- Department of Pharmacy; Hutzel Women's Hospital; Detroit MI USA
| | - David Edwards
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences; Wayne State University; Detroit MI USA
| | - Ronald L. Thomas
- Division of Biostatistics; Children's Hospital of Michigan; Detroit MI USA
| | - Girija Natarajan
- Division of Neonatology; Children's Hospital of Michigan; Wayne State University; Detroit MI USA
| |
Collapse
|
52
|
Every 36-h gentamicin dosing in neonates with hypoxic-ischemic encephalopathy receiving hypothermia. J Perinatol 2013; 33:778-82. [PMID: 23702622 PMCID: PMC3762884 DOI: 10.1038/jp.2013.59] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/18/2013] [Accepted: 03/26/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine the impact of a change in the empiric gentamicin dose from 5 mg kg(-1) every 24 h (Q24 h period) to 5 mg kg every 36 h (Q36 h period) on target drug concentration achievement in neonates with hypoxic ischemic encephalopathy (HIE) receiving therapeutic hypothermia. STUDY DESIGN Gentamicin drug concentrations in neonates with HIE receiving therapeutic hypothermia were examined during two time periods in a retrospective chart review. During the initial treatment period (November 2007 to March 2010; n=29), neonates received Q24 h period. During the second treatment period (January 2011 to May 2012; n=23), the dose was changed to Q36 h period. Cooling criteria and protocol remained the same between treatment periods. Gentamicin drug concentrations including achievement of target trough concentrations (<2 mg l(-1)) were compared between treatment periods. Individual Bayesian estimates of gentamicin clearance were also compared. RESULT Neonates with an elevated trough concentration >2 mg l(-1) decreased from 38 to 4% with implementation of a Q36-h dosing interval (P<0.007). The mean gentamicin trough concentration was 2.0 ± 0.8 mg l(-1) during the Q24 h period and 0.9 ± 0.4 mg l(-1) during the Q36 h period (P<0.001). Peak concentrations were minimally impacted (Q24 h 11.4 ± 2.3 mg l(-1) vs Q36 h 10.0 ± 1.9 mg l(-1); P=0.05). The change in gentamicin trough concentration could not be accounted for by differences in gentamicin clearance between treatment periods (P=0.9). CONCLUSION A 5 mg kg(-1) every 36-h gentamicin dosing strategy in neonates with HIE receiving therapeutic hypothermia improved achievement of target trough concentration <2 mg l(-1), while still providing high peak concentration exposure.
Collapse
|
53
|
Smit E, Liu X, Gill H, Sabir H, Jary S, Thoresen M. Factors associated with permanent hearing impairment in infants treated with therapeutic hypothermia. J Pediatr 2013; 163:995-1000. [PMID: 23885964 DOI: 10.1016/j.jpeds.2013.06.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/15/2013] [Accepted: 06/11/2013] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To define the incidence of hearing impairment, document plasma gentamicin concentrations, and identify factors associated with permanent hearing impairment in infants subjected to therapeutic hypothermia for moderate or severe neonatal encephalopathy. STUDY DESIGN Data were collected prospectively in a regional center providing therapeutic hypothermia. Cooled infants at ≥ 36 weeks gestation with moderate or severe neonatal encephalopathy were analyzed if a full dataset was available (n = 108), including clinical variables and gentamicin trough levels. Infants with hearing impairment were identified, and survivors were followed up with neurodevelopmental evaluation at age 18 months. Stepwise logistic regression identified factors associated with hearing impairment. RESULTS Nine infants died, and among the survivors, 10.1% developed a permanent hearing impairment. The trough gentamicin level was above the recommended cutoff of 2 mg/L in 37% of the infants in the entire cohort and in 90% of the infants with hearing impairment. Logistic regression analysis identified high trough gentamicin level, low cord pH, and hypoglycemia (<46.8 mg/dL) in the first postnatal hour as significantly associated with hearing impairment. The need for inotropic support was close to significant (P = .055). CONCLUSION Hearing impairment was a common finding among cooled infants. Plasma gentamicin levels were commonly >2 mg/L. Based on these findings, we propose changes in gentamicin dosing interval and trough level monitoring to minimize the risk of potentially toxic levels in cooled newborns.
Collapse
Affiliation(s)
- Elisa Smit
- School of Clinical Sciences, University of Bristol, Bristol, United Kingdom; Neonatal Intensive Care Unit, St Michael's Hospital, University Hospitals Bristol, Bristol, United Kingdom
| | | | | | | | | | | |
Collapse
|
54
|
Frymoyer A, Meng L, Bonifacio SL, Verotta D, Guglielmo BJ. Gentamicin pharmacokinetics and dosing in neonates with hypoxic ischemic encephalopathy receiving hypothermia. Pharmacotherapy 2013; 33:718-26. [PMID: 23553582 DOI: 10.1002/phar.1263] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To evaluate the pharmacokinetics of gentamicin in neonates with hypoxic ischemic encephalopathy (HIE) receiving hypothermia and to identify an empiric gentamicin dosing strategy in this population that optimizes achievement of target peak and trough concentrations. DESIGN Population pharmacokinetic study using retrospective medical record data. SETTING Tertiary neonatal intensive care unit. PATIENTS A total of 29 full-term neonates diagnosed with HIE treated with hypothermia who received gentamicin and underwent therapeutic drug monitoring MEASUREMENT AND MAIN RESULTS Patient demographics and gentamicin concentration data were retrospectively collected over a 2-year period. A population-based pharmacokinetic model was developed using nonlinear mixed-effects modeling (NONMEM). Using the developed model, Monte Carlo simulations were performed to evaluate the probability of achieving target peak (> 6 mg/L) and trough (< 2 mg/L) gentamicin concentrations for various potential dosing regimens. A one-compartment model best described the available gentamicin concentration data. Birthweight and serum creatinine significantly influenced gentamicin clearance. For the typical study neonate (birthweight 3.3 kg, serum creatinine 0.9 mg/dl), clearance was 0.034 L/hour/kg and volume was 0.52 L/kg. At a 24-hour dosing interval, Monte Carlo simulations predicted target gentamicin peak and trough concentrations could not be reliably achieved at any dose. At a 36-hour dosing interval, a dose of 4-5 mg/kg is predicted to achieve target gentamicin peak and trough concentrations in more than 90% of neonates. CONCLUSIONS Gentamicin clearance is decreased in neonates with HIE treated with hypothermia compared with previous reports in nonasphyxiated normothermic full-term neonates. A prolonged 36-hour dosing interval will be needed to achieve target gentamicin trough concentrations in this population. Further prospective evaluation of this dosing recommendation is needed.
Collapse
Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Palo Alto, California 94304, USA.
| | | | | | | | | |
Collapse
|
55
|
Burton AJ, Giguère S, Warner L, Alhamhoom Y, Arnold RD. Effect of age on the pharmacokinetics of a single daily dose of gentamicin sulfate in healthy foals. Equine Vet J 2012; 45:507-11. [DOI: 10.1111/j.2042-3306.2012.00683.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 09/09/2012] [Indexed: 11/30/2022]
Affiliation(s)
- A. J. Burton
- Department of Large Animal Medicine; College of Veterinary Medicine; University of Georgia; Athens; Georgia; USA
| | - S. Giguère
- Department of Large Animal Medicine; College of Veterinary Medicine; University of Georgia; Athens; Georgia; USA
| | - L. Warner
- Department of Large Animal Medicine; College of Veterinary Medicine; University of Georgia; Athens; Georgia; USA
| | - Y. Alhamhoom
- Department of Pharmaceutical and Biomedical Sciences; College of Pharmacy; College of Pharmacy; University of Georgia; Athens; Georgia; USA
| | - R. D. Arnold
- Department of Pharmaceutical and Biomedical Sciences; College of Pharmacy; College of Pharmacy; University of Georgia; Athens; Georgia; USA
| |
Collapse
|
56
|
Alshaikh B, Dersch-Mills D, Taylor R, Akierman AR, Yusuf K. Extended interval dosing of gentamicin in premature neonates ≤ 28-week gestation. Acta Paediatr 2012; 101:1134-9. [PMID: 22897142 DOI: 10.1111/j.1651-2227.2012.02820.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To evaluate an extended interval dosing (EID) regimen of gentamicin in neonates ≤28-week gestation. METHODS In 2008, an EID regimen for gentamicin was introduced for all neonates admitted to the NICU in Calgary. The dosing interval was based on a 22 h level after the first dose of 5mg/kg. We conducted an observational study in 33 infants ≤28-week gestation on the EID regimen from the first day of life and compared gentamicin peak and trough levels with a historical control of 34 infants who received gentamicin in a dose of 2.5 mg/kg every 24 h (TID, traditional interval dosing). RESULTS In the EID group, based on the 22 h level, dosing interval was 36 h in 20 neonates and 48 h in 13 neonates. All neonates, except one, achieved therapeutic peak and trough levels. Compared to the TID group, the EID group had higher peak levels (median 9.8 μg/mL vs. 4.6 μg/mL, p < 0.001) with no difference in trough levels. With target peak levels of 5-12 μg/mL and trough levels of <2 μg/mL, a higher proportion of neonates in the TID group would need dose adjustment. CONCLUSION In neonates ≤ 28-week gestation, an EID regimen from day one of life, using a single level 22 h after the first dose for dosing interval, achieves therapeutic peak and trough levels and more optimum peak levels as compared to a TID regimen.
Collapse
Affiliation(s)
- Belal Alshaikh
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, University of Calgary, Alberta, Canada
| | | | | | | | | |
Collapse
|
57
|
Tayman C, Rayyan M, Allegaert K. Neonatal pharmacology: extensive interindividual variability despite limited size. J Pediatr Pharmacol Ther 2012; 16:170-84. [PMID: 22479159 DOI: 10.5863/1551-6776-16.3.170] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Providing safe and effective drug therapy to neonates requires knowledge of the impact of development on the pharmacokinetics and pharmacodynamics of drugs. Although maturational changes are observed throughout childhood, they are most prominent during the first year of life. Several of these processes overlap, making development an extremely dynamic system in the newborn compared with that in infants, children, or adults. Changes in body composition and porportions, liver mass, metabolic activity, and renal function collectively affect the pharmacokinetic behavior of medications. Instead of simply adapting doses by scaling adult or pediatric doses on the basis of a patient's weight and/or body surface area, integrated knowledge of clinical maturation and developmental pharmacology is critical to the safe and effective use of medications in neonates. Unfortunately, the effects of human ontogeny on both pharmacokinetics and pharmacodynamics have not been well established in these early stages of life, and information regarding the influence of developmental changes on the pharmacodynamics of medications is even more limited. Theoretically, age-dependent variations in receptor number and affinity for drugs have significant potential to influence an individual's response to drug therapy. In this review, some of the relevant covariates of pharmacokinetics and pharmacodynamics in neonates are reviewed and illustrated based on the published literature.
Collapse
|
58
|
Dersch-Mills D, Akierman A, Alshaikh B, Yusuf K. Validation of a dosage individualization table for extended-interval gentamicin in neonates. Ann Pharmacother 2012; 46:935-42. [PMID: 22739714 DOI: 10.1345/aph.1r029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Extended-interval aminoglycoside dosing is increasingly used in neonates; however, guidance on how to monitor concentrations and adjust dosages accordingly is limited. OBJECTIVE To prospectively validate the use of a 22-hour gentamicin concentration dosing table for the individualization of extended-interval dosing in the neonatal population by examining the peak and trough concentrations achieved through its use. METHODS A prospective observational study was carried out on gentamicin concentrations achieved using a 22-hour post-first-dose gentamicin concentration dosing table for determining dosing intervals in neonates. Neonates (N = 104) in the first week of life, gestational age 23 weeks to full term, in level II and III neonatal intensive care units were included. Neonates were given gentamicin 5 mg/kg intravenously; a table using 22-hour post-first-dose gentamicin concentrations was then used to individualize dosing intervals. Pre- and post-serum gentamicin concentrations on the dosing interval indicated were measured with the second or third doses and used to calculate the peak and trough concentrations achieved. RESULTS Use of the 22-hour post-first-dose gentamicin concentration dosing table resulted in dosing intervals that provided appropriate peak (mean 10.55 mg/L) and trough (mean 0.75 mg/L) concentrations (with second or third doses) in all neonates. All patients had trough concentrations less than 2 mg/L, and 73% had a trough concentration less than 1 mg/L. No peak concentrations were less than 5 mg/L, 82% of patients had a peak concentration from 5 to 12 mg/L, and the remaining 18% had concentrations from 12.1 to 16 mg/L. Peak and trough concentrations were similar across all gestational ages. CONCLUSIONS Use of a 22-hour post-first-dose gentamicin concentration dosing table to individualize extended-interval gentamicin dosages in neonates resulted in appropriate peak and trough concentrations in all neonates studied. Use of this table will result in appropriate extended-interval aminoglycoside dosages in neonates early in treatment, using a single serum concentration.
Collapse
|
59
|
De Cock RFW, Allegaert K, Schreuder MF, Sherwin CMT, de Hoog M, van den Anker JN, Danhof M, Knibbe CAJ. Maturation of the glomerular filtration rate in neonates, as reflected by amikacin clearance. Clin Pharmacokinet 2012; 51:105-17. [PMID: 22229883 DOI: 10.2165/11595640-000000000-00000] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVES During the newborn period and early infancy, renal function matures, resulting in changes in the glomerular filtration rate (GFR). This study was performed to quantify developmental changes in the GFR in (pre)term neonates by use of amikacin clearance as proof of concept. The model was used to derive a rational dosing regimen in comparison with currently used dosing regimens for amikacin. METHODS Population pharmacokinetic modelling was performed in nonlinear mixed-effect modelling software (NONMEM version 6.2) using data from 874 neonates obtained from two previously published datasets (gestational age 24-43 weeks; postnatal age 1-30 days; birthweight 385-4650 g). The influence of different age-related, weight-related and other covariates was investigated. The model was validated both internally and externally. RESULTS Postmenstrual age was identified as the most significant covariate on clearance. However, the combination of birthweight and postnatal age proved to be superior to postmenstrual age alone. Birthweight was best described using an allometric function with an exponent of 1.34. Postnatal age was identified using a linear function with a slope of 0.2, while co-administration of ibuprofen proved to be a third covariate. Current bodyweight was the most important covariate for the volume of distribution, using an allometric function. The external evaluation supported the prediction of the final pharmacokinetic model. This analysis illustrated clearly that the currently used dosing regimens for amikacin in reference handbooks may possibly increase the risk of toxicities and should be revised. Consequently, a new model-based dosing regimen based on current bodyweight and postnatal age was derived. CONCLUSIONS Amikacin clearance, reflecting the GFR in neonates, can be predicted by birthweight representing the antenatal state of maturation of the kidney, postnatal age representing postnatal maturation, and co-administration of ibuprofen. Finally, the model reflects maturation of the GFR, allowing for adjustments of dosing regimens for other renally excreted drugs in preterm and term neonates.
Collapse
|
60
|
Hutson JR, Weitzman S, Schechter T, Arceci RJ, Kim RB, Finkelstein Y. Pharmacokinetic and pharmacogenetic determinants and considerations in chemotherapy selection and dosing in infants. Expert Opin Drug Metab Toxicol 2012; 8:709-22. [PMID: 22509821 DOI: 10.1517/17425255.2012.680884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION There is a lack of high-quality data regarding optimal chemotherapy dosage regimens among infants. Dosing regimens for chemotherapy during the first year of life are commonly based on empiric recommendations extrapolated from older children; however, balancing efficacy and toxicity is critical as severe adverse drug reactions may lead to treatment failure or reduced adherence to needed medications. AREAS COVERED This review describes pharmacokinetic and pharmacogenetic considerations when administering chemotherapeutic agents to infants. Examples of commonly used agents are provided with practical recommendations for dosing adjustments. EXPERT OPINION Optimal chemotherapy for children and infants in particular has lagged behind the remarkable progress in cancer treatment and it is clear that far more basic and clinical research are needed with respect to the mechanistic basis of age-dependent differences in pharmacokinetic parameters. More recent studies which have combined pharmacokinetic data with clinical toxicity and outcome data have resulted in a number of more evidence-based guidelines at least for the initial chemotherapy dosing; however, at present, the dosing of chemotherapy drugs in neonates and infants remains largely empiric.
Collapse
Affiliation(s)
- Janine R Hutson
- University of Toronto, Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, 555 University Ave, Toronto ON, M5G 1X8, Canada
| | | | | | | | | | | |
Collapse
|
61
|
Rao SC, Srinivasjois R, Hagan R, Ahmed M. One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates. Cochrane Database Syst Rev 2011:CD005091. [PMID: 22071818 DOI: 10.1002/14651858.cd005091.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Animal studies and trials in older children and adults suggest that a one dose per day regimen of gentamicin is superior to a multiple doses per day regimen. OBJECTIVES To compare the efficacy and safety of one dose per day compared to multiple doses per day of gentamicin in suspected or proven sepsis in neonates. SEARCH METHODS Eligible studies were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, April 2011), MEDLINE (1966 to April 2011), EMBASE 1980 to April 2011, and CINAHL (December 1982 to April 2011). Abstracts of the Society for Pediatric Research were searched from 1980 to 2010 inclusive. SELECTION CRITERIA All randomised or quasi randomised controlled trials comparing one dose per day ( 'once a day') compared to multiple doses per day ( 'multiple doses a day') of gentamicin to newborn infants < 28 days of life. DATA COLLECTION AND ANALYSIS Data collection and analysis was performed according to the standards of the Cochrane Neonatal Review Group. MAIN RESULTS Eleven studies were included (N = 574) and nineteen excluded. All infants in both 'once a day' as well as 'multiple doses a day' regimen showed adequate clearance of sepsis [typical RD 0.00 (95% CI - 0.19 to 0.19); 3 trials; N = 36]. For the other primary outcome measures relating to gentamicin pharmacokinetics 'once a day' dosing of gentamicin was superior. 'Once a day' gentamicin regimen was associated with less failures to attain peak level of at least 5 µg/ml [typical RR 0.22 (95% CI 0.11 to 0.47); 9 trials; N = 422] and less failures to achieve trough levels of < 2 µg/ml [typical RR 0.38 (95% CI 0.27 to 0.55); 11 trials N = 503] compared to 'multiple doses a day' regimen.Ototoxicity and nephrotoxicity were not noted with either of the treatment regimens. AUTHORS' CONCLUSIONS There is insufficient evidence from the currently available RCTs to conclude whether 'once a day' or 'multiple doses a day' regimen of gentamicin is superior in treating proven neonatal sepsis. However, data suggests that pharmacokinetic properties of 'once a day' gentamicin regimen are superior to 'multiple doses a day' regimen in that it achieves higher peak levels while avoiding toxic trough levels. There is no change in nephrotoxicity or auditory toxicity. Based on this assessment of pharmacokinetics, 'once a day regimen' may be superior in treating neonatal sepsis in neonates greater than 32 weeks gestation.
Collapse
Affiliation(s)
- Shripada C Rao
- Centre for Neonatal Research and Education, King Edward Memorial Hospital for Women and Princess Margaret Hospital for Children, Perth Western Australia, Australia.
| | | | | | | |
Collapse
|
62
|
Pharmacokinetic-pharmacodynamic model for gentamicin and its adaptive resistance with predictions of dosing schedules in newborn infants. Antimicrob Agents Chemother 2011; 56:179-88. [PMID: 22037853 DOI: 10.1128/aac.00694-11] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Gentamicin is commonly used in the management of neonatal infections. Development of adaptive resistance is typical for aminoglycosides and reduces the antibacterial effect. There is, however, a lack of understanding of how this phenomenon influences the effect of different dosing schedules. The aim was to develop a pharmacokinetic-pharmacodynamic (PKPD) model that describes the time course of the bactericidal activity of gentamicin and its adaptive resistance and to investigate different dosing schedules in preterm and term newborn infants based on the developed model. In vitro time-kill curve experiments were conducted on a strain of Escherichia coli (MIC of 2 mg/liter). The gentamicin exposure was either constant (0.125 to 16 mg/liter) or dynamic (simulated concentration-time profiles in a kinetic system with peak concentrations of 2.0, 3.9, 7.8, and 16 mg/liter given as single doses or as repeated doses every 6, 12, or 24 h). Semimechanistic PKPD models were fitted to the bacterial counts in the NONMEM (nonlinear mixed effects modeling) program. A model with compartments for growing and resting bacteria, with a function allowing the maximal bacterial killing of gentamicin to reduce with exposure, characterized both the fast bactericidal effect and the adaptive resistance. Despite a lower peak concentration, preterm neonates were predicted to have a higher bacterial killing effect than term neonates for the same per-kg dose because of gentamicin's longer half-life. The model supported an extended dosing interval of gentamicin in preterm neonates, and for all neonates, dosing intervals of 36 to 48 h were as effective as a 24-h dosing interval for the same total dose.
Collapse
|
63
|
Kadambari S, Heath PT, Sharland M, Lewis S, Nichols A, Turner MA. Variation in gentamicin and vancomycin dosage and monitoring in UK neonatal units. J Antimicrob Chemother 2011; 66:2647-50. [DOI: 10.1093/jac/dkr351] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
64
|
Cooper AC, Commers AR, Finkelstein M, Lipnik PG, Tollefson LM, Wilcox RA, Hoff DS. Otoacoustic Emission Screen Results in Critically Ill Neonates Who Received Gentamicin in the First Week of Life. Pharmacotherapy 2011; 31:649-57. [DOI: 10.1592/phco.31.7.649] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
65
|
Rao SC, Srinivasjois R, Hagan R, Ahmed M. Cochrane Review: One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
66
|
Venisse N, Boulamery A. [Level of evidence for therapeutic drug monitoring of aminoglycosides]. Therapie 2011; 66:39-44. [PMID: 21466776 DOI: 10.2515/therapie/2011001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 04/27/2010] [Indexed: 12/20/2022]
Abstract
Aminoglycosides are major antibiotics indicated for the treatment of infection with gram-negative bacilli. They are characterized by high clinical effectiveness but their main drawback is the occurrence of toxicity in a significant number of patients. Pharmacokinetic parameters of aminoglycosides exhibit wide inter-individual variability and the relationships between concentration and effect have been clearly demonstrated. Consistent studies have demonstrated that therapeutic drug monitoring (TDM) of aminoglycosides administered in multiple daily doses was cost-effective in maximising antibiotic efficacy and/or reducing incidence of toxicity. Therefore TDM of aminoglycosides should be considered "essential". Level of evidence for TDM of aminoglycosides administered once daily is not so clearly demonstrated however it should be highly recommended.
Collapse
Affiliation(s)
- Nicolas Venisse
- Service de Toxicologie et Pharmacocinétique, CHU, Poitiers, France. n.venisse@chu--poitiers.fr
| | | | | |
Collapse
|
67
|
Abstract
Therapeutic drug monitoring (TDM) is central to optimize drug efficacy in children, because the pharmacokinetics and pharmacodynamics of most drugs differ greatly between children and adults. Many factors should be analyzed to implement TDM in the pediatric population, including a validated pharmacological parameter and an analytical method adapted to children as limited sampling volumes and high sensitivity are required. The use of population approaches, new analytical methods such as saliva and dried blood spots, and pharmacodynamic monitoring give attractive options to improve TDM, individualize therapy in order to optimize efficacy and reduce adverse drug reactions.
Collapse
Affiliation(s)
- Wei Zhao
- Department of Pediatric Pharmacology and Pharmacogenetics, Clinical Investigation Center, CIC Inserm 9202, French network of Pediatric Investigation Centers, Hôpital Robert Debré, 48 Boulevard Sérurier, 75935 Paris, France
| | | |
Collapse
|
68
|
de Hoog M, van den Anker JN. Therapeutic drug monitoring of aminoglycosides in neonates. Clin Pharmacokinet 2010; 48:343-4; author reply 344-5. [PMID: 19566117 DOI: 10.2165/00003088-200948050-00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
69
|
Hitron AE, Sun Y, Scarpace SB. Accuracy of Empiric Gentamicin Dosing Guidelines in Neonates. J Pediatr Pharmacol Ther 2010. [DOI: 10.5863/1551-6776-15.4.264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
ABSTRACTOBJECTIVETo evaluate the accuracy of a neonatal gentamicin nomogram to achieve therapeutic gentamicin serum concentrations without further adjustment, allowing for decreased serum drug monitoringMETHODSRetrospective single center review of all gentamicin pharmacokinetic evaluations in patients ≤ 30 days of life from July 2005 – June 2007. Patients were evaluated for postnatal age, gestational age, weight, serum creatinine, dose/interval, serum drug peaks and troughs, results of discharge hearing test and recent use of indomethacin. Logistic regression was utilized to determine potential factors impacting overall dosing accuracy, potentially allowing for decreased therapeutic drug monitoring. Factors found to be significant were incorporated into new guidelines which were evaluated through pharmacokinetic modeling.RESULTSOverall accuracy rate was 84% when empiric dosing guidelines were utilized; 16% of all doses were changed due to supratherapeutic troughs and 1% were changed due to subtherapeutic peaks. Variables found to impact the necessity for dose changes incuded gestational age (p≤0.001), weight (p≤0.001), indomethacin use (p≤0.001), number of indomethacin doses used (p≤0.001 and p=0.009 for 1–3 and 4–6 doses, respectively), and SCr in patients ≥ 7 days old (p=0.028); however, only gestational age remained a significant predictor when all other factors were considered (p=0.008). The current guidelines were changed to account for increased troughs in patients ≤ 28 weeks gestation and examined through pharmacokinetic modeling. Pharmacokinetic modeling of the new guidelines predicted an overall accuracy of 94%.CONCLUSIONSFrom the data gathered regarding the accuracy in patients ≥ 35 weeks gestation, we recommend to decrease therapeutic drug monitoring within this cohort. Utilizing the results of regression analysis, the current guidelines have been adjusted to allow for increased clearance in patients ≤ 28 weeks gestation, although they still need to be prospectively evaluated.
Collapse
Affiliation(s)
- Anna E. Hitron
- Pharmacy Services, UK HealthCare, University of Kentucky College of Pharmacy Department of Pharmacy Practice and Science
| | - Yao Sun
- Division of Neonatology, Department of Pediatric Neonatology
| | - Sarah B. Scarpace
- Department of Clinical Pharmacy, University of California, San Francisco, California
| |
Collapse
|
70
|
Rao SC, Ahmed M, Hagan R. One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates. Cochrane Database Syst Rev 2006:CD005091. [PMID: 16437518 DOI: 10.1002/14651858.cd005091.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Gentamicin is widely used in the treatment of suspected or proven neonatal sepsis. Animal studies and systematic reviews from trials in older children and adults suggest that a one dose per day regimen is superior to a multiple doses per day regimen. Pharmacokinetic studies and retrospective audits in neonatal population also favour once a day administration of gentamicin. However, there is no consensus regarding the dose interval regimen in the neonatal population. OBJECTIVES To compare the efficacy and safety of one dose per day compared to multiple doses per day of gentamicin in suspected or proven sepsis in neonates. SEARCH STRATEGY Eligible studies were identified by searching MEDLINE (March 2005), EMBASE 1980 - 2004, Oxford Database of Perinatal Trials, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2005) and CINAHL (December 1982 - March 2005). Abstracts of the Society for Pediatric Research were hand searched from 1980 to 2004 inclusive. No language restrictions were applied. SELECTION CRITERIA All randomised or quasi randomised controlled trials comparing one dose per day ( 'once a day') compared to multiple doses per day ( 'multiple doses a day') of gentamicin to newborn infants < 28 days of life. DATA COLLECTION AND ANALYSIS Methodological quality of eligible studies was assessed according to allocation concealment, blinding of intervention, blinding of outcome assessment and completeness of follow up. Data were sought regarding effects on clinical efficacy, pharmacokinetic efficacy, ototoxicity and nephrotoxicity of the two regimens. When appropriate, meta-analysis was conducted to provide a pooled estimate of effect. For categorical data, the typical relative risk (RR), typical risk difference (RD) and number needed to treat (NNT) with 95% confidence intervals (CI) were calculated. Continuous data were analysed using weighted mean difference (WMD). MAIN RESULTS Twenty four studies were initially identified. Thirteen were excluded and eleven studies (N = 574) included. All studies compared the effectiveness and safety of 'once a day' versus 'multiple doses a day' regimen of gentamicin in newborn infants. Only one study enrolled infants less than 32 weeks gestation. All except one trial used intravenous infusion. One trial used gentamicin as a bolus dose over one minute. Two trials used intramuscular gentamicin in some of their study infants. For the primary outcome of 'clearance of sepsis', all infants in both 'once a day' as well as 'multiple doses a day' regimen showed adequate clearance of sepsis [Typical RD 0.00 (95% CI - 0.19, 0.19); 3 trials; N = 36]. For the other primary outcome measures relating to gentamicin pharmacokinetics, 'once a day dosing' of gentamicin was superior. 'Once a day' gentamicin regimen is associated with less failures to attain peak level of at least 5 microg/ml [Typical RR 0.22 (95% CI 0.11, 0.47); Typical RD -0.13 (95% CI -0.19, -0.08); 9 trials; N = 422]; less failures to achieve trough levels of < 2 microg/ml [Typical RR 0.38 (95% CI 0.27, 0.55); Typical RD -0.22 (95% CI -0.29, -0.15); 11 trials N = 503]; higher peak levels [WMD 2.58 (95% CI 2.26, 2.89); 10 trials; N = 440] and lower trough levels [WMD -0.57 (95% CI -0.69, -0.44); 10 trials; N = 440] compared to 'multiple doses a day' regimen. Ototoxicity and nephrotoxicity were not noted with either of the treatment regimens. Significant heterogeneity was noted for some of the outcomes measured. Hence the results need to be interpreted with caution. Possible reasons for heterogeneity are different gestational ages of study infants and the timing of collection of blood samples in relation to a particular dose and the day of therapy on which the samples were collected. AUTHORS' CONCLUSIONS There is insufficient evidence from the currently available RCTs to conclude whether 'once a day' or 'multiple doses a day' regimen of gentamicin is superior in treating proven neonatal sepsis. However data suggests that pharmacokinetic properties of 'once a day' gentamicin regimen are superior to 'multiple doses a day' regimen in that it achieves higher peak levels while avoiding toxic trough levels. There is no change in nephrotoxicity or auditory toxicity. Based on this assessment of pharmacokinetics, 'once a day regimen' may be superior in treating neonatal sepsis in neonates more than 32 weeks gestation.
Collapse
Affiliation(s)
- S C Rao
- Royal North Shore Hospital, Neonatology, Pacific Highway, St Leonards, NSW, Australia, 2065.
| | | | | |
Collapse
|