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Stefani M, Musgrave K, Sevastos J, Penny M, Day RO, Roberts DM. Optimizing the dosing of vancomycin in patients receiving intermittent haemodialysis with low-flux filters, and the potential impact of dosing software. Nephrology (Carlton) 2023; 28:534-539. [PMID: 37394830 DOI: 10.1111/nep.14198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 07/04/2023]
Abstract
AIM Iterative approaches to vancomycin dosing (e.g., dosing when trough concentrations <15-20 mg/L) can be inadequate. Computer-guided dosing may be superior but has not been evaluated in patients with kidney failure receiving replacement therapy. We evaluated vancomycin concentrations using a hospital protocol and a pharmacokinetic software. We measured vancomycin clearance by the FX8 low-flux filter because data are absent. METHODS We retrospectively reviewed records of adults with kidney failure requiring replacement therapy receiving vancomycin and dialysed with the FX8 low-flux filter, and calculated the proportion of pre-dialysis concentrations that were within, above or below a specified range. One and two-compartment models in the pharmacokinetic software were assessed by computing mean prediction error (MPE) and root mean square error (RMSE) of observed versus predicted concentrations. Vancomycin extracorporeal clearance was prospectively determined using the extraction method. RESULTS In 24 patients (34 courses; 139 paired observed and predicted concentrations), 62/139 (45%) pre-dialysis concentrations were 15-25 mg/L, 29/139 (21%) were above, and 48/139 (35%) were below. MPE for the one-compartment model was -0.2 mg/L, RMSE 5.3 mg/L. MPE for the two-compartment model was 2.0 mg/L, RMSE 5.6 mg/L. Excluding the first paired concentrations, the subsequent MPE (n = 105) using one-compartment model was -0.5 mg/L, RMSE 5.6 mg/L. The MPE for the two-compartment model was 2.1 mg/L, RMSE 5.8 mg/L. The median extracorporeal clearance was 70.7 mL/min (range: 10.3-130.3; n = 22). CONCLUSIONS Vancomycin dosing was suboptimal and the pharmacokinetic software was not sufficiently predictive. These may improve with a loading dose. The substantial removal of vancomycin by low-flux filters is not accounted for by the models tested.
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Affiliation(s)
- Maurizio Stefani
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Department of Infectious Diseases, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
| | - Kirsty Musgrave
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Jacob Sevastos
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Mark Penny
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Richard O Day
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, University of NSW, Darlinghurst, New South Wales, Australia
- Department of Renal Medicine and Transplantation, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
- Edith Collins Centre, Drug Health Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
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Ables M, Welch RW, Walley B. Development and Assessment of Vancomycin Dosing Utilizing AUC/MIC Protocol in Patients With End-Stage Renal Disease (ESRD) on Intermittent Hemodialysis (IHD). J Pharm Pract 2023:8971900231198927. [PMID: 37715731 DOI: 10.1177/08971900231198927] [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: 09/18/2023]
Abstract
Purpose: Vancomycin is commonly prescribed for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, including patients with end stage renal disease (ESRD) receiving intermittent hemodialysis (IHD). Infection is the second-leading cause of mortality in this patient population; therefore, optimizing vancomycin dosing is essential. New guidelines recommend using the ratio of area under the curve (AUC)/minimal inhibitory concentration (MIC) dosing with a target of 400-600 to maximize efficacy and minimize vancomycin nephrotoxicity. Summary: A retrospective chart review was performed to assess the current protocol for vancomycin dosing in ESRD patients on IHD at a community hospital in North Mississippi. A protocol was developed for dosing vancomycin utilizing AUC/MIC targets in this patient population. The study included all inpatient adults with ESRD receiving IHD at least 3 times weekly and receiving vancomycin. Data collection occurred in two phases. The first phase of data collection occurred before implementation of the new protocol and assessed the current vancomycin protocol effectiveness. In phase II of data collection, an assessment of the newly developed protocol utilizing similar data collected in phase I was conducted. Conclusions: It is thought that the difference in treatment outcomes and AUC/MIC targets is due to decreased immune function in this population. For this reason, we set our goal pre-dialysis level at 20-25 mg/dL, rather than 17-25 mg/dL, which correlates with an AUC/MIC of 480-600. It is important to quickly achieve therapeutic levels for the patients that do have MRSA to improve outcomes, to sustain these levels, and to reduce adverse events and costs.
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Affiliation(s)
- Mary Ables
- Department of Pharmacy, Baptist Memorial Hospital GTR, Columbus, MS, USA
| | - Ron W Welch
- Department of Pharmacy, Baptist Memorial Hospital GTR, Columbus, MS, USA
| | - Brittany Walley
- Department of Pharmacy, Baptist Memorial Hospital GTR, Columbus, MS, USA
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Lewis SJ, Jang SM, Mueller BA. Vancomycin and daptomycin dosing recommendations in patients receiving home hemodialysis using Monte Carlo simulation. BMC Nephrol 2023; 24:270. [PMID: 37710245 PMCID: PMC10500909 DOI: 10.1186/s12882-023-03314-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Few drug dosing recommendations for patients receiving home hemodialysis (HHD) have been published which has hindered the adoption of HHD. HHD regimens vary widely and differ considerably from conventional, thrice weekly, in-center hemodialysis in terms of treatment frequency, duration and blood and dialysate flow rates. Consequently, vancomycin and daptomycin clearances in HHD are also likely to be different, consequently HHD dosing regimens must be developed to ensure efficacy and minimize toxicity when these antibiotics are used. Many HHD regimens are used clinically, this study modeled ten common HHD regimens and determined optimal vancomycin and daptomycin dosing for each HHD regimen. METHODS Monte Carlo simulations using pharmacokinetic data derived from the literature and demographic data from a large HHD program treating patients with end stage kidney disease were incorporated into a one-compartment pharmacokinetic model. Virtual vancomycin and daptomycin doses were administered post-HHD and drug exposures were determined in 5,000 virtual patients receiving ten different HHD regimens. Serum concentration monitoring with subsequent dose changes was incorporated into the vancomycin models. Pharmacodynamic target attainment rates were determined for each studied dose. The lowest possible doses that met predefined targets in virtual patients were chosen as optimal doses. RESULTS HHD frequency, total dialysate volumes and HHD durations influenced drug exposure and led to different dosing regimens to meet targets. Antibiotic dosing regimens were identified that could meet targets for 3- and 7-h HHD regimens occurring every other day or 4-5 days/week. HHD regimens with 3-day interdialytic periods required higher doses prior to the 3-day period. The addition of vancomycin serum concentration monitoring allowed for calculation of necessary dosing changes which increased the number of virtual subjects meeting pharmacodynamic targets. CONCLUSIONS Doses of vancomycin and daptomycin that will meet desired pharmacodynamic targets in HHD are dependent on patient and HHD-specific factors. Doses used in conventional thrice weekly hemodialysis are unlikely to meet treatment goals. The antibiotic regimens paired with the HHD parameters studied in this analysis are likely to meet goals but require clinical validation.
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Affiliation(s)
- Susan J. Lewis
- University of Findlay College of Pharmacy, 1000 N. Main Street, Findlay, OH 45840 USA
- Mercy Health - St. Anne Hospital, Toledo, OH 43623 USA
| | - Soo Min Jang
- Proacture Consulting Group, 6905 Telegraph Rd, Bloomfield Hills, MI 48304 USA
| | - Bruce A. Mueller
- University of Michigan College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109-1065 USA
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Alghanem SS, Al-Otaibi M, Awad A. Practices, Knowledge, and Attitudes of Nephrologists Towards Prescribing and Monitoring Vancomycin at Dialysis Centers. Expert Rev Anti Infect Ther 2023; 21:1011-1019. [PMID: 37551135 DOI: 10.1080/14787210.2023.2245566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 06/07/2023] [Accepted: 07/13/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Vancomycin dosing protocols are varied in the literature for hemodialysis patients. This study sought to determine nephrologists' practices, knowledge, attitudes, and barriers toward prescribing and monitoring vancomycin at dialysis centers. METHODS A cross-sectional and multi-center study was conducted in Kuwait using a validated self-administered questionnaire among 168 nephrologists. Descriptive and comparative analyses were performed using SPSS (version 28). RESULTS The response rate was 75% (n = 126). Over half of nephrologists frequently prescribed a vancomycin loading dose of 1000 mg (53.2%) and a maintenance dose of 500 mg (51.6%) to all patients. Their overall median (IQR) percentage knowledge about the therapeutic monitoring of vancomycin was 66.7% (33.3) and was found to be higher in nephrologists aged ≤ 40 years and in registrars/senior registrars (p < 0.05). Their overall median (IQR) attitude score was 4.0 (1.0) [positive attitude]. Nephrologists with > 15 years of practice experience expressed higher attitudes (p < 0.05). The top two perceived barriers were a lack of clear local hospital/national guidelines (60.3%) for vancomycin dosing in dialysis and inconsistencies among different dosing references and guidelines (51.6%). CONCLUSION Findings showed that nephrologists have varying practices, moderate knowledge, and positive attitudes toward prescribing and monitoring vancomycin and highlight the need for interventions to overcome the perceived barriers.
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Affiliation(s)
- Sarah S Alghanem
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Safat, Kuwait
| | - Manar Al-Otaibi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Safat, Kuwait
| | - Abdelmoneim Awad
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Safat, Kuwait
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Zelenitsky SA, Ariano RE. An updated vancomycin dosing protocol for initiating therapy in patients undergoing intermittent high-flux hemodialysis. Am J Health Syst Pharm 2022; 79:1006-1010. [PMID: 35234825 DOI: 10.1093/ajhp/zxac066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To design an updated vancomycin dosing protocol for initiating therapy in patients undergoing chronic intermittent high-flux hemodialysis (iHFHD) that is congruent with the revised 2020 consensus guidelines for therapeutic drug monitoring (TDM). METHODS Monte Carlo simulation methods were used to study vancomycin dosing for patients on iHFHD. Vancomycin regimens were constructed as intravenous infusions (for intradialytic administration) of a loading dose and maintenance doses 3 times weekly during subsequent dialysis sessions. Vancomycin plasma concentrations were simulated, and the probability of target attainment (PTA) for a 24-hour area under the time-concentration curve (AUC24) of 400 to 700 mg • h/L was determined. Standardized weight-based (ie, dose-banding) regimens were investigated, and an optimized protocol was selected based on TDM target attainment and practical considerations for use in the dialysis setting. RESULTS The proposed vancomycin dosing protocol (for intradialytic administration) specifies 3 regimens: (1) a 1,500-mg loading dose and 750-mg maintenance doses for patients weighing 50 kg to 69 kg; (2) a 2,000-mg loading dose and 1,000-mg maintenance doses for patients weighing 70 kg to 89 kg; and (3) a 2,500-mg loading dose and 1,250-mg maintenance doses for patients weighing 90 kg to 110 kg. In a simulated hemodialysis population (n = 1,000), the proposed protocol delivered median (interquartile range [IQR]) loading and maintenance doses of 25.0 (23.4-26.6) mg/kg and 12.5 (11.8-13.3) mg/kg, respectively. The PTA for an AUC24 of 400 to 700 mg • h/L was 74.7% on day 1 and 70.8% on day 8, with less than 10% of values exceeding the target range. CONCLUSION Our proposed dosing protocol for patients undergoing iHFHD offers an updated and practical approach for initiating vancomycin therapy that can be optimized with early TDM.
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Affiliation(s)
- Sheryl A Zelenitsky
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada, and Department of Pharmacy, St. Boniface Hospital, Winnipeg, Canada
| | - Robert E Ariano
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada, and Department of Pharmacy, St. Boniface Hospital, Winnipeg, Canada
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Alonso-Bastida A, Adam-Medina M, Posada-Gómez R, Salazar-Piña DA, Osorio-Gordillo GL, Vela-Valdés LG. Dynamic of Glucose Homeostasis in Virtual Patients: A Comparison between Different Behaviors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:716. [PMID: 35055537 PMCID: PMC8775377 DOI: 10.3390/ijerph19020716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/23/2021] [Accepted: 01/01/2022] [Indexed: 02/04/2023]
Abstract
This work presents a mathematical model of homeostasis dynamics in healthy individuals, focusing on the generation of conductive data on glucose homeostasis throughout the day under dietary and physical activity factors. Two case studies on glucose dynamics for populations under conditions of physical activity and sedentary lifestyle were developed. For this purpose, two types of virtual populations were generated, the first population was developed according to the data of a total of 89 physical persons between 20 and 75 years old and the second was developed using the Monte Carlo approach, obtaining a total of 200 virtual patients. In both populations, each participant was classified as an active or sedentary person depending on the physical activity performed. The results obtained demonstrate the capacity of virtual populations in the generation of in-silico approximations similar to those obtained from in-vivo studies. Obtaining information that is only achievable through specific in-vivo experiments. Being a tool that generates information for the approach of alternatives in the prevention of the development of type 2 Diabetes.
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Affiliation(s)
- Alexis Alonso-Bastida
- Electronic Engineering Department, TecNM/CENIDET, Cuernavaca 62490, Morelos, Mexico; (M.A.-M.); (G.-L.O.-G.); (L.G.V.-V.)
| | - Manuel Adam-Medina
- Electronic Engineering Department, TecNM/CENIDET, Cuernavaca 62490, Morelos, Mexico; (M.A.-M.); (G.-L.O.-G.); (L.G.V.-V.)
| | | | | | - Gloria-Lilia Osorio-Gordillo
- Electronic Engineering Department, TecNM/CENIDET, Cuernavaca 62490, Morelos, Mexico; (M.A.-M.); (G.-L.O.-G.); (L.G.V.-V.)
| | - Luis Gerardo Vela-Valdés
- Electronic Engineering Department, TecNM/CENIDET, Cuernavaca 62490, Morelos, Mexico; (M.A.-M.); (G.-L.O.-G.); (L.G.V.-V.)
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Widanski MA. Reassessing predialysis goals for serious methicillin-resistant Staphylococcus aureus infections. Am J Health Syst Pharm 2021; 78:1667-1669. [PMID: 34059872 DOI: 10.1093/ajhp/zxab236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Matt A Widanski
- UC Health Daniel Drake Center for Post Acute Care, Cincinnati, OH, USA
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Lewis SJ, Nolin TD. New Vancomycin Dosing Guidelines for Hemodialysis Patients: Rationale, Caveats, and Limitations. KIDNEY360 2021; 2:1313-1315. [PMID: 35369653 PMCID: PMC8676380 DOI: 10.34067/kid.0000192021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Susan J. Lewis
- Department of Pharmacy Practice, College of Pharmacy, University of Findlay, Findlay, Ohio
| | - Thomas D. Nolin
- Department of Pharmacy and Therapeutics, School of Pharmacy, and Department of Medicine Renal-Electrolyte Division, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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