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de Hoop-Sommen MA, van der Heijden JEM, Freriksen JJM, Greupink R, de Wildt SN. Pragmatic physiologically-based pharmacokinetic modeling to support clinical implementation of optimized gentamicin dosing in term neonates and infants: proof-of-concept. Front Pediatr 2023; 11:1288376. [PMID: 38078320 PMCID: PMC10702772 DOI: 10.3389/fped.2023.1288376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/02/2023] [Indexed: 02/12/2024] Open
Abstract
Introduction Modeling and simulation can support dosing recommendations for clinical practice, but a simple framework is missing. In this proof-of-concept study, we aimed to develop neonatal and infant gentamicin dosing guidelines, supported by a pragmatic physiologically-based pharmacokinetic (PBPK) modeling approach and a decision framework for implementation. Methods An already existing PBPK model was verified with data of 87 adults, 485 children and 912 neonates, based on visual predictive checks and predicted-to-observed pharmacokinetic (PK) parameter ratios. After acceptance of the model, dosages now recommended by the Dutch Pediatric Formulary (DPF) were simulated, along with several alternative dosing scenarios, aiming for recommended peak (i.e., 8-12 mg/L for neonates and 15-20 mg/L for infants) and trough (i.e., <1 mg/L) levels. We then used a decision framework to weigh benefits and risks for implementation. Results The PBPK model adequately described gentamicin PK. Simulations of current DPF dosages showed that the dosing interval for term neonates up to 6 weeks of age should be extended to 36-48 h to reach trough levels <1 mg/L. For infants, a 7.5 mg/kg/24 h dose will reach adequate peak levels. The benefits of these dose adaptations outweigh remaining uncertainties which can be minimized by routine drug monitoring. Conclusion We used a PBPK model to show that current DPF dosages for gentamicin in term neonates and infants needed to be optimized. In the context of potential uncertainties, the risk-benefit analysis proved positive; the model-informed dose is ready for clinical implementation.
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Affiliation(s)
- Marika A. de Hoop-Sommen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joyce E. M. van der Heijden
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jolien J. M. Freriksen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rick Greupink
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia N. de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Intensive Care, Radboud University Medical Center, Nijmegen, Netherlands
- Intensive Care and Pediatric Surgery, Erasmus MC, Rotterdam, Netherlands
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2
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Kato H, Hagihara M, Matsuda H, Iwamoto T. Gentamicin Pharmacokinetics and Optimal Dosage in Infant Patients: A Case Report and Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15360. [PMID: 36430078 PMCID: PMC9691146 DOI: 10.3390/ijerph192215360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/08/2022] [Accepted: 11/18/2022] [Indexed: 06/16/2023]
Abstract
Gentamicin is an aminoglycoside antibiotic that is mostly used for the pediatric population. While the pediatric population is classified into neonates, infants, children, and adolescents based on developmental or maturational changes, infants are often overlooked in research. Three infant cases receiving gentamicin are presented to illustrate the pharmacokinetics and optimum dosage of gentamicin. Three infant patients received gentamicin (5.6-7.5 mg/kg/day) for urinary tract infections (UTIs) or bacteremia caused by Enterobacter aerogenes. The trough (Cmin) and peak (Cpeak) concentrations of gentamicin were 0.2-1.8 and 8.9 mg/L, respectively. The Cmin of a patient receiving gentamicin at 9.0 mg/kg/day was 3.3 mg/L, and the patient showed a decrease in urinary volume. The other two patients fully recovered from the infection and did not experience any adverse events. Additionally, we reviewed three studies regarding infant patients receiving gentamicin. The studies used gentamicin therapy for Gram-negative pathogen infections and UTIs caused by Escherichia coli and Enterococcus faecalis. The Cmin and Cpeak of patients receiving gentamicin at 2.2-7.5 mg/kg/day were 0.58-2.15 mg/kg and 4.67-8.88 mg/L, respectively. All patients were cured without any adverse events. Gentamicin dosages below 7.5 mg/kg/day may be effective and safe for use in infant patients. However, the optimal dosing regimen of gentamicin in infant patients is controversial, and limited data are available.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University Hospital, Nagakute 480-1195, Japan
| | - Hiroko Matsuda
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
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3
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Hodiamont CJ, van den Broek AK, de Vroom SL, Prins JM, Mathôt RAA, van Hest RM. Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review. Clin Pharmacokinet 2022; 61:1075-1094. [PMID: 35754071 PMCID: PMC9349143 DOI: 10.1007/s40262-022-01143-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.
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Affiliation(s)
- Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Suzanne L de Vroom
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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4
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Sands K, Spiller OB, Thomson K, Portal EAR, Iregbu KC, Walsh TR. Early-Onset Neonatal Sepsis in Low- and Middle-Income Countries: Current Challenges and Future Opportunities. Infect Drug Resist 2022; 15:933-946. [PMID: 35299860 PMCID: PMC8921667 DOI: 10.2147/idr.s294156] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 02/17/2022] [Indexed: 12/18/2022] Open
Abstract
Neonatal sepsis is defined as a systemic infection within the first 28 days of life, with early-onset sepsis (EOS) occurring within the first 72h, although the definition of EOS varies in literature. Whilst the global incidence has dramatically reduced over the last decade, neonatal sepsis remains an important cause of neonatal mortality, highest in low- and middle-income countries (LMICs). Symptoms at the onset of neonatal sepsis can be subtle, and therefore EOS is often difficult to diagnose from clinical presentation and laboratory testing and blood cultures are not always conclusive or accessible, especially in resource limited countries. Although the World Health Organisation (WHO) currently advocates a ß-lactam, and gentamicin for first line treatment, availability and cost influence the empirical antibiotic therapy administered. Antibiotic treatment of neonatal sepsis in LMICs is highly variable, partially caused by factors such as cost of antibiotics (and who pays for them) and access to certain antibiotics. Antimicrobial resistance (AMR) has increased considerably over the past decade and this review discusses current microbiology data available in the context of the diagnosis, and treatment for EOS. Importantly, this review highlights a large variability in data availability, methodology, availability of diagnostics, and aetiology of sepsis pathogens.
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Affiliation(s)
- Kirsty Sands
- Ineos Institute of Antimicrobial Research, Department of Zoology, University of Oxford, Oxford, UK
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Owen B Spiller
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Kathryn Thomson
- Ineos Institute of Antimicrobial Research, Department of Zoology, University of Oxford, Oxford, UK
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | | | | | - Timothy R Walsh
- Ineos Institute of Antimicrobial Research, Department of Zoology, University of Oxford, Oxford, UK
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
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5
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Darlow CA, da Costa RMA, Ellis S, Franceschi F, Sharland M, Piddock L, Das S, Hope W. Potential Antibiotics for the Treatment of Neonatal Sepsis Caused by Multidrug-Resistant Bacteria. Paediatr Drugs 2021; 23:465-484. [PMID: 34435316 PMCID: PMC8418595 DOI: 10.1007/s40272-021-00465-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 01/26/2023]
Abstract
Neonatal sepsis causes up to an estimated 680,000 deaths annually worldwide, predominantly in low- and middle-income countries (LMICs). A significant and growing proportion of bacteria causing neonatal sepsis are resistant to multiple antibiotics, including the World Health Organization-recommended empiric neonatal sepsis regimen of ampicillin/gentamicin. The Global Antibiotic Research and Development Partnership is aiming to develop alternative empiric antibiotic regimens that fulfil several criteria: (1) affordable in LMIC settings; (2) activity against neonatal bacterial pathogens, including extended-spectrum β-lactamase producers, gentamicin-resistant Gram-negative bacteria, and methicillin-resistant Staphylococcus aureus (MRSA); (3) a licence for neonatal use or extensive experience of use in neonates; and (4) minimal toxicities. In this review, we identify five antibiotics that fulfil these criteria: amikacin, tobramycin, fosfomycin, flomoxef, and cefepime. We describe the available characteristics of each in terms of mechanism of action, resistance mechanisms, clinical pharmacokinetics, pharmacodynamics, and toxicity profile. We also identify some knowledge gaps: (1) the neonatal pharmacokinetics of cefepime is reliant on relatively small and limited datasets, and the pharmacokinetics of flomoxef are also reliant on data from a limited demographic range and (2) for all reviewed agents, the pharmacodynamic index and target has not been definitively established for both bactericidal effect and emergence of resistance, with many assumed to have an identical index/target to similar class molecules. These five agents have the potential to be used in novel combination empiric regimens for neonatal sepsis. However, the data gaps need addressing by pharmacokinetic trials and pharmacodynamic characterisation.
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Affiliation(s)
- Christopher A Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.
| | | | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Laura Piddock
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
- Antimicrobials Research Group, Institute for Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
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6
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Allegaert K, van den Anker J. Dose-Related Adverse Drug Events in Neonates: Recognition and Assessment. J Clin Pharmacol 2021; 61 Suppl 1:S152-S160. [PMID: 34185907 PMCID: PMC8361661 DOI: 10.1002/jcph.1827] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/04/2021] [Indexed: 12/23/2022]
Abstract
The efficacy and safety of a drug is dose or exposure related, and both are used to assess the benefit-risk balance of a given drug and ultimately to decide on the specific drug license, including its dose and indication(s). Unfortunately, both efficacy and safety are much more difficult to establish in neonates, resulting in very few drugs licensed for use in this vulnerable population. This review will focus on dose-related adverse events in neonates. Besides the regulatory classification on seriousness, adverse event assessment includes aspects related to signal detection, causality, and severity. Disentangling confounders from truly dose-related adverse drug events remains a major challenge, as illustrated for drug-induced renal impairment, drug-induced liver injury, and neurodevelopmental outcome. Causality assessment, using either routine tools (Naranjo algorithm, World Health Organization's Uppsala Monitoring Center causality tool) or a Naranjo algorithm tailored to neonates, still does not sufficiently and reliably document causality in neonates. Finally, very recently, a first neonatal severity-grading tool for neonates has been developed. Following the development of advanced pharmacokinetic approaches and techniques to predict and assess drug exposure, additional efforts are needed to truly and fully assess dose adverse drug events. To further operationalize the recently developed tools on causality and severity, reference databases on a palette of biomarkers and outcome variables and their covariates are an obvious next step. These databases should subsequently be integrated in modeling efforts to truly explore safety outcome, including aspects associated with or caused by drug dose or exposure.
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Affiliation(s)
- Karel Allegaert
- Department of Development and RegenerationKU LeuvenLeuvenBelgium
- Department of Pharmaceutical and Pharmacological SciencesKU LeuvenLeuvenBelgium
- Department of Hospital PharmacyErasmus MC University Medical CenterRotterdamthe Netherlands
| | - John van den Anker
- Division of Clinical PharmacologyChildren's National Health HospitalWashingtonDCUSA
- Pediatric Pharmacology and PharmacometricsUniversity Children's Hospital Basel (UKBB)University of BaselBaselSwitzerland
- Intensive Care and Department of Pediatric SurgeryErasmus MC Sophia Children's HospitalRotterdamThe Netherlands
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7
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Review of the Applications of Biomedical Compositions Containing Hydroxyapatite and Collagen Modified by Bioactive Components. MATERIALS 2021; 14:ma14092096. [PMID: 33919199 PMCID: PMC8122483 DOI: 10.3390/ma14092096] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/11/2021] [Accepted: 04/19/2021] [Indexed: 02/06/2023]
Abstract
Regenerative medicine is becoming a rapidly evolving technique in today’s biomedical progress scenario. Scientists around the world suggest the use of naturally synthesized biomaterials to repair and heal damaged cells. Hydroxyapatite (HAp) has the potential to replace drugs in biomedical engineering and regenerative drugs. HAp is easily biodegradable, biocompatible, and correlated with macromolecules, which facilitates their incorporation into inorganic materials. This review article provides extensive knowledge on HAp and collagen-containing compositions modified with drugs, bioactive components, metals, and selected nanoparticles. Such compositions consisting of HAp and collagen modified with various additives are used in a variety of biomedical applications such as bone tissue engineering, vascular transplantation, cartilage, and other implantable biomedical devices.
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8
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Optimizing Aminoglycoside Dosing Regimens for Critically Ill Pediatric Patients with Augmented Renal Clearance: a Convergence of Parametric and Nonparametric Population Approaches. Antimicrob Agents Chemother 2021; 65:AAC.02629-20. [PMID: 33526481 DOI: 10.1128/aac.02629-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/22/2021] [Indexed: 11/20/2022] Open
Abstract
Augmented renal clearance (ARC) can occur in critically ill pediatric patients receiving aminoglycosides such as gentamicin and tobramycin, yet optimal dosing strategies for ARC are undefined. We evaluated the probability of achieving efficacious or toxic exposures in pediatrics. Parallel population modeling of concentration strategies were pursued using Pmetrics v1.5.2 (nonparametric) and Monolix v2019R2 (parametric). Bayesian exposures were used to classify ARC based on total clearance (CL). The effects of serum creatinine (SCR), creatinine clearance (CRCL), total body weight (TBW), postnatal age (PNA), and ARC were explored as covariates. The probabilities of target attainment (PTA) (i.e., maximum concentration [C max]/MIC, area under the concentration-time curve [AUC]/MIC) and of toxic exposure (PTE) (i.e., minimum concentration [C min] > 2 μg/ml) were calculated according to PNA and ARC. A total of 123 patients (1 to 21 years old, 56% female) contributed 304 concentrations. A two-compartment model was superior to a one-compartment model in both approaches. Bayesian posterior predicted concentrations from the nonparametric base model fit the data well (R 2 = 0.96) and classified 34 patients as having ARC (28%). Both the nonparametric and parametric approaches resulted in allometrically scaling of TBW on volume (V) and clearance (CL). ARC modified CL and central V. CRCL and a maturation function modified CL. ARC was associated with a 1.49- versus 1.66-fold increase in CL and a 1.56- versus 1.66-fold increase in the central V (nonparametric versus parametric). A high dose of 12 mg/kg of body weight/day was required to achieve adequate PTA when MICs were 1 to 2 μg/ml; ARC lowered achievable MICs. When PNA was <2 years, PTE was increased. Aminoglycoside monotherapy should be avoided in critically ill pediatric patients with ARC when MICs exceed 1 μg/ml, as optimal exposures are unachievable with standard dosing.
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Murphy HJ, Thomas B, Van Wyk B, Tierney SB, Selewski DT, Jetton JG. Nephrotoxic medications and acute kidney injury risk factors in the neonatal intensive care unit: clinical challenges for neonatologists and nephrologists. Pediatr Nephrol 2020; 35:2077-2088. [PMID: 31605211 DOI: 10.1007/s00467-019-04350-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/21/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023]
Abstract
Neonatal acute kidney injury (AKI) is common. Critically ill neonates are at risk for AKI for many reasons including the severity of their underlying illnesses, prematurity, and nephrotoxic medications. In this educational review, we highlight four clinical scenarios in which both the illness itself and the medications indicated for their treatment are risk factors for AKI: sepsis, perinatal asphyxia, patent ductus arteriosus, and necrotizing enterocolitis. We review the available evidence regarding medications commonly used in the neonatal period with known nephrotoxic potential, including gentamicin, acyclovir, indomethacin, vancomycin, piperacillin-tazobactam, and amphotericin. We aim to illustrate the complexity of decision-making involved for both neonatologists and pediatric nephrologists when managing infants with these conditions and advocate for ongoing multidisciplinary collaboration in the development of better AKI surveillance protocols and AKI mitigation strategies to improve care for these vulnerable patients.
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Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Brady Thomas
- Stead Family Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - Brynna Van Wyk
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa, 200 Hawkins Drive, 2027 BT, Iowa City, IA, 52241, USA
| | - Sarah B Tierney
- Department of Pharmaceutical Care, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa, 200 Hawkins Drive, 2027 BT, Iowa City, IA, 52241, USA.
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10
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Bergenwall M, Walker SAN, Elligsen M, Iaboni DC, Findlater C, Seto W, Ng E. Optimizing gentamicin conventional and extended interval dosing in neonates using Monte Carlo simulation - a retrospective study. BMC Pediatr 2019; 19:318. [PMID: 31492162 PMCID: PMC6729057 DOI: 10.1186/s12887-019-1676-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although aminoglycosides are routinely used in neonates, controversy exists regarding empiric dosing regimens. The objectives were to determine gentamicin pharmacokinetics in neonates, and develop initial mg/kg dosing recommendations that optimized target peak and trough concentration attainment for conventional and extended-interval dosing (EID) regimens. METHODS Patient demographics and steady-state gentamicin concentration data were retrospectively collected for 60 neonates with no renal impairment admitted to a level III neonatal intensive care unit. Mean pharmacokinetics were calculated and multiple linear regression was performed to determine significant covariates of clearance (L/h) and volume of distribution (L). Classification and regression tree (CART) analysis identified breakpoints for significant covariates. Monte Carlo Simulation (MCS) was used to determine optimal dosing recommendations for each CART-identified sub-group. RESULTS Gentamicin clearance and volume of distribution were significantly associated with weight at gentamicin initiation. CART-identified breakpoints for weight at gentamicin initiation were: ≤ 850 g, 851-1200 g, and > 1200 g. MCS identified that a conventional dose of gentamicin 3.5 mg/kg given every 48 h or an EID of 8-9 mg/kg administered every 72 h in neonates weighing ≤ 850 g, and every 24 and 48 h, respectively, in neonates weighing 851-1200 g, provided the best probability of attaining conventional (peak: 5-10 mg/L and trough: ≤ 2 mg/L) and EID targets (peak:12-20 mg/L, trough:≤ 0.5 mg/L). Insufficient sample size in the > 1200 g neonatal group precluded further investigation of this weight category. CONCLUSIONS This study provides initial gentamicin dosing recommendations that optimize target attainment for conventional and EID regimens in neonates weighing ≤ 1200 g. Prospective validation and empiric dose optimization for neonates > 1200 g is needed.
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Affiliation(s)
- Monique Bergenwall
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Present Address: Grandview Medical Centre Family Health Team, 167 Hespeler Rd, Cambridge, ON N1R 3H7 Canada
| | - Sandra A. N. Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Sunnybrook Health Sciences Centre Research Institute, Toronto, ON Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
| | - Dolores C. Iaboni
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Carla Findlater
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Winnie Seto
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Department of Pharmacy, Hospital for Sick Children, Toronto, ON Canada
| | - Eugene Ng
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Department of Paediatrics, University of Toronto, Toronto, ON Canada
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11
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Liu J, Li Y, Feng Y, Pan L, Xie Z, Yan Z, Zhang L, Li M, Zhao J, Sun J, Hong L. Patterned progression of gut microbiota associated with necrotizing enterocolitis and late onset sepsis in preterm infants: a prospective study in a Chinese neonatal intensive care unit. PeerJ 2019; 7:e7310. [PMID: 31367483 PMCID: PMC6657676 DOI: 10.7717/peerj.7310] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 06/17/2019] [Indexed: 12/25/2022] Open
Abstract
Necrotizing enterocolitis (NEC) and late-onset sepsis (LOS) are two common premature birth complications with high morbidity and mortality. Recent studies in Europe and America have linked gut microbiota dysbiosis to their etiology. However, similar studies in Asian populations remain scant. In this pilot study, we profiled gut microbiota of 24 Chinese preterm infants from birth till death or discharge from NICU. Four of them developed NEC and three developed LOS. Unexpectedly, we detected highly-diversified microbiota with similar compositions in all patients shortly after birth. However, as patients aged, the microbial diversities in case groups differed significantly from that of the control group. These differences emerged after the third day of life and persisted throughout the course of both NEC and LOS. Using a Zero-Inflated Beta Regression Model with Random Effects (ZIBR), we detected higher Bacillus (p = 0.032) and Solibacillus (p = 0.047) before the onset of NEC and LOS. During NEC progression, Enterococcus, Streptococcus and Peptoclostridium were the dominant genera while during LOS progression; Klebsiella was the only dominant genus that was also detected by the diagnostic hemoculture. These results warrant further studies to identify causative microbial patterns and underlying mechanisms.
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Affiliation(s)
- Jiayi Liu
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Yuqing Li
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Yi Feng
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Liya Pan
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Zhoulonglong Xie
- Department of Surgery, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Zhilong Yan
- Department of Surgery, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Li Zhang
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China
| | - Mingkun Li
- Key Laboratory of Genomic and Precision Medicine, Beijing Institute of Genomics, Chinese Academy of Sciences, Beijing, China.,Center for Excellence in Animal Evolution and Genetics, Chinese Academy of Sciences, Kunming, China
| | - Jianhua Zhao
- Shanghai Majorbio Bio-pharm Technology Co., Ltd, Shanghai, China
| | - Jianhua Sun
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Li Hong
- Department of Clinical Nutrition, Shanghai Children's Medical Center, School of Medicine Shanghai Jiao Tong University, Shanghai, China
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12
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Rodgers AM, McCrudden MTC, Courtenay AJ, Kearney MC, Edwards KL, Ingram RJ, Bengoechea J, Donnelly RF. Control of Klebsiella pneumoniae Infection in Mice by Using Dissolving Microarray Patches Containing Gentamicin. Antimicrob Agents Chemother 2019; 63:e02612-18. [PMID: 30858214 PMCID: PMC6496091 DOI: 10.1128/aac.02612-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/27/2019] [Indexed: 12/22/2022] Open
Abstract
Using a murine model of Klebsiella pneumoniae bacterial infection, we demonstrate that gentamicin dissolving microarray patches, applied to murine ears, could control K. pneumoniae infection. Mice treated with microarray patches had reduced bacterial burden in the nasal-associated lymphoid tissue and lungs compared with their untreated counterparts. This proof of concept study represents the first published data on the in vivo delivery of the antibiotic gentamicin via dissolving microarray patches, resulting in the control of bacterial infection.
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Affiliation(s)
- Aoife M Rodgers
- School of Pharmacy, Medical Biology Centre, Queens University Belfast, Belfast, United Kingdom
| | - Maelíosa T C McCrudden
- School of Pharmacy, Medical Biology Centre, Queens University Belfast, Belfast, United Kingdom
| | - Aaron J Courtenay
- School of Pharmacy, Medical Biology Centre, Queens University Belfast, Belfast, United Kingdom
| | - Mary-Carmel Kearney
- School of Pharmacy, Medical Biology Centre, Queens University Belfast, Belfast, United Kingdom
| | - Katherine L Edwards
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry & Biomedical Science, Queens University Belfast, Belfast, United Kingdom
| | - Rebecca J Ingram
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry & Biomedical Science, Queens University Belfast, Belfast, United Kingdom
| | - Jose Bengoechea
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry & Biomedical Science, Queens University Belfast, Belfast, United Kingdom
| | - Ryan F Donnelly
- School of Pharmacy, Medical Biology Centre, Queens University Belfast, Belfast, United Kingdom
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13
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ÇÖBDEN A, ÇAMURCU Y, BULUT ÇÖBDEN S, SOFU H, ÜÇPUNAR H, SEVENCAN A, DEMİREL H. Audiometric threshold shifts after total knee arthroplasty by using gentamicin-loaded
bone cement. Turk J Med Sci 2019; 49:514-518. [PMID: 30893980 PMCID: PMC7018343 DOI: 10.3906/sag-1710-135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background/aim The aim of this study was to investigate postoperative audiometric threshold shifts in patients who underwent
primary total knee arthroplasty (TKA) using gentamicin-loaded bone cement (GLBC) in comparison with the ones who underwent
TKA without GLBC. Materials and methods Forty patients (gentamicin group) who underwent primary TKA using GLBC and 29 patients (control group)
who underwent primary TKA using standard bone cement were included in this prospective case-control study. Baseline pure-tone
audiometric evaluation was performed preoperatively and repeated at the postoperative third day for all patients. Control audiometric
evaluation was performed weekly for patients who were diagnosed with ototoxicity according to audiometric threshold shifts. Results Ototoxicity was diagnosed in 8 of 40 patients (20%) in the gentamicin group according to postoperative audiometric threshold
shifts, whereas no ototoxicity was observed in the control group. Patients who were diagnosed with ototoxicity had no permanent
audiometric threshold shifts in follow-up audiometric evaluation and these patients had no clinical complaints of difference in hearing. Conclusion According to our results, audiometric threshold shifts can be detected in patients who undergo primary TKA using
gentamicin loaded bone cement. However, no permanent shifts were observed during close follow-up.
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Affiliation(s)
- Adem ÇÖBDEN
- Department of Orthopedics and Traumatology, Ministry of Health, Kayseri City Hospital, KayseriTurkey
| | - Yalkın ÇAMURCU
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan Binali Yıldırım University, ErzincanTurkey
- * To whom correspondence should be addressed. E-mail:
| | - Serap BULUT ÇÖBDEN
- Department of Otorhinolaryngology, Ministry of Health, Kayseri City Hospital, KayseriTurkey
| | - Hakan SOFU
- Department of Orthopedics and Traumatology, Bahçelievler Medical Park Hospital, İstanbulTurkey
| | - Hanifi ÜÇPUNAR
- Department of Orthopedics and Traumatology, Faculty of Medicine, Erzincan Binali Yıldırım University, ErzincanTurkey
| | - Ahmet SEVENCAN
- Department of Orthopedics and Traumatology, Şanlıurfa Education and Research Hospital, ŞanlıurfaTurkey
| | - Hüseyin DEMİREL
- Department of Orthopedics and Traumatology, Sivas Numune Hospital, SivasTurkey
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14
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Le Saux N, Robinson J. Aminoglycosides-alive and well in treatment of pediatric infections: A case of benefit versus risk. JOURNAL OF THE ASSOCIATION OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASE CANADA = JOURNAL OFFICIEL DE L'ASSOCIATION POUR LA MICROBIOLOGIE MEDICALE ET L'INFECTIOLOGIE CANADA 2019; 4:1-5. [PMID: 36338783 PMCID: PMC9603187 DOI: 10.3138/jammi.2018.09.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 06/16/2023]
Affiliation(s)
- Nicole Le Saux
- University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Joan Robinson
- University of Alberta, Stollery Children’s Hospital, Edmonton, Alberta, Canada
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15
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Cuzzolin L, Agostino R. Antibiotic Use in a Cohort of Extremely Low Birth Weight Neonates: Focus on Off-Label Uses and Prescription Behaviour. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/pp.2018.99029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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