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Briand A, Bernier L, Pincivy A, Roumeliotis N, Autmizguine J, Marsot A, Métras MÉ, Thibault C. Prolonged Beta-Lactam Infusions in Children: A Systematic Review and Meta-Analysis. J Pediatr 2024; 275:114220. [PMID: 39097265 DOI: 10.1016/j.jpeds.2024.114220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/02/2024] [Accepted: 07/29/2024] [Indexed: 08/05/2024]
Abstract
OBJECTIVE To assess whether beta-lactam extended or continuous beta-lactam infusions (EI/CI) improve clinical outcomes in children with proven or suspected bacterial infections. STUDY DESIGN We included observational and interventional studies that compared beta-lactam EI or CI with standard infusions in children less than 18 years old, and reported on mortality, hospital or intensive care unit length of stay, microbiological cure, and/or clinical cure. Data sources included PubMed, Medline, EBM Reviews, EMBASE, and CINAHL and were searched from January 1, 1980, to November 3, 2023. Thirteen studies (2945 patients) were included: 5 randomized control trials and 8 observational studies. Indications for antimicrobial therapies and clinical severity varied, ranging from cystic fibrosis exacerbation to critically ill children with bacteriemia. RESULTS EI and CI were not associated with a reduction in mortality in randomized control trials (n = 1464; RR 0.93, 95% CI 0.71, 1.21), but were in observational studies (n = 833; RR 0.43, 95% CI 0.19, 0.96). We found no difference in hospital length of stay. Results for clinical and microbiological cures were heterogeneous and reported as narrative review. The included studies were highly heterogeneous, limiting the strength of our findings. The lack of shared definitions for clinical and microbiological cure outcomes precluded analysis. CONCLUSIONS EI and CI were not consistently associated with reduced mortality or length of stay in children. Results were conflicting regarding clinical and microbiological cures. More well-designed studies targeting high-risk populations are necessary to determine the efficacy of these alternative dosing strategies.
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Affiliation(s)
- Annabelle Briand
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; Department of Pediatrics, CHU Sainte-Justine, Montreal QC, Canada
| | - Laurie Bernier
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Alix Pincivy
- Library Services, CHU Sainte-Justine, Montreal, QC, Canada
| | - Nadia Roumeliotis
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada; CHU Sainte Justine Research Center, Montreal, QC, Canada
| | - Julie Autmizguine
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; CHU Sainte Justine Research Center, Montreal, QC, Canada; Department of Pharmacology and Physiology, Université de Montréal, CHU Sainte-Justine, Montreal, QC, Canada; Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada; CHU Sainte Justine Research Center, Montreal, QC, Canada
| | - Marie-Élaine Métras
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada; Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada; CHU Sainte Justine Research Center, Montreal, QC, Canada
| | - Celine Thibault
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada; CHU Sainte Justine Research Center, Montreal, QC, Canada.
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2
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Shaniv D, Allegaert K. Applied pharmacokinetics to improve pharmacotherapy in neonatal and paediatric intensive care units: focus on correct dose selection. Arch Dis Child Educ Pract Ed 2024; 109:184-190. [PMID: 38408792 DOI: 10.1136/archdischild-2023-326325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/13/2024] [Indexed: 02/28/2024]
Abstract
Drug dosing and exposure throughout childhood are constantly affected by maturational changes like weight, age or body surface area. In neonatal and paediatric intensive care units (NICU and PICU, respectively), drug dosing and exposure are further impacted by non-maturational changes. These changes are related to factors such as sepsis, cardiac failure, acute kidney injury, extracorporeal circuits or drug-drug interactions (DDIs) resulting from polypharmacy.This potentially complex situation may alter drug pharmacokinetics to result in greater-than-usual intrapatient and interpatient drug exposure variability. These effects may call for individual dosage adjustments. Dosage adjustments may apply to both loading doses or maintenance doses, which should be used as appropriate, depending on the specific characteristics of a given drug. Phenobarbital and vancomycin dosing are hereby used as illustrations.To optimise dose selection in NICU/PICU settings, we suggest to consider therapeutic drug monitoring integrated in model-informed precision dosing, and to familiarise oneself with existing paediatric drug formularies as well as DDI databases/search engines. Paediatric clinical pharmacologists and pharmacists can hereby guide clinicians with no prior experience on how to properly apply these data sources to day-to-day practice in individual patients or specific subpopulations of NICU or PICU patients.
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Affiliation(s)
- Dotan Shaniv
- Pharmacy Services, Kaplan Medical Center, Clalit Health Services, Rehovot, Israel
- Neonatal Intensive Care Unit, Kaplan Medical Center, Clarit Health Services, Rehovot, Israel
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, Netherlands
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3
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Gebreyesus MS, Dresner A, Wiesner L, Coetzee E, Verschuuren T, Wasmann R, Denti P. Dose optimization of cefazolin in South African children undergoing cardiac surgery with cardiopulmonary bypass. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 38962872 DOI: 10.1002/psp4.13196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 05/27/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024] Open
Abstract
Cefazolin is an antibiotic used to prevent surgical site infections. During cardiac surgery with cardiopulmonary bypass (CPB), its efficacy target could be underachieved. We aimed to develop a population pharmacokinetic model for cefazolin in children and optimize the prophylactic dosing regimen. Children under 25 kg undergoing cardiac surgery with CPB and receiving cefazolin at standard doses (50 mg/kg IV every 4-6 h) were included in this analysis. A population pharmacokinetic model and Monte Carlo simulations were used to evaluate the probability of target attainment (PTA) for efficacy and toxicity with the standard regimen and an alternative regimen of continuous infusion, where loading and maintenance doses were calculated from model-derived individual parameters. Twenty-two patients were included, with median (range) age, body weight, and eGFR of 19.5 (1-94) months, 8.7 (2-21) kg, and 116 (48-159) mL/min, respectively. Six patients received an additional dose in the CPB circuit. A two-compartment disposition model with an additional compartment for the CPB was developed, including weight-based allometric scaling and eGFR. For a 10 kg patient with eGFR of 120 mL/min/1.73 m2, clearance was estimated as 0.856 L/h. Simulations indicated that the standard dosing regimen fell short of achieving the efficacy target >40% of the time within a dosing duration and in patients with good renal function, PTA ranged from <20% to 70% for the smallest to the largest patients, respectively, at high MICs. In contrast, the alternative regimen consistently maintained target concentrations throughout the procedure for all patients while using a lower overall dose.
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Affiliation(s)
- Manna Semere Gebreyesus
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Alexandra Dresner
- Department of Anesthesia and Perioperative Medicine, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ettienne Coetzee
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Tess Verschuuren
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Roeland Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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4
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Alsultan A, Aldawsari MR, Alturaiq NK, Syed SA, Alsubai A, Kurdee Z, Alsubaie S, Alqahtani S, Abouelkheir M. Evaluation of pharmacokinetic pharmacodynamic target attainment of meropenem in pediatric patients. Pediatr Neonatol 2024; 65:386-390. [PMID: 38218717 DOI: 10.1016/j.pedneo.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/27/2023] [Accepted: 09/08/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Meropenem is a widely used carbapenem for treating severe pediatric infections. However, few studies have assessed its pharmacokinetics/pharmacodynamics (PK/PD) in pediatric patients. This study aimed to evaluate the proportion of Saudi pediatric patients achieving the PK/PD target of meropenem. METHODS A prospective observational study was conducted at King Saud University Medical City from July to September 2022. Pediatric patients receiving meropenem for suspected or proven infections were included in the study. The primary outcome was the percentage of patients achieving the recommended PK/PD target for critically ill or non-critically ill pediatric patients. RESULTS The study included 30 patients (nine neonates and 21 older pediatric patients). All neonates were critically ill. Among them, 55 % achieved the PK/PD target of 100 % free time above the MIC. In older ICU pediatric patients, only 11 % attained this target, whereas 58 % of older pediatrics in the general wards achieved the PK/PD target of 50 % free time above the MIC. Augmented renal clearance (ARC) was identified in 57 % of our pediatric patient population, none of whom achieved the recommended PK/PD targets. The median trough concentrations in patients with and without ARC were 0.75 and 1.3 μg/mL, respectively (P < 0.05). CONCLUSIONS The majority of patients in our cohort did not achieve the PK/PD target for meropenem. ARC emerged as a major risk factor for target attainment failure in both critically ill and non-critically ill pediatric patients.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia.
| | - Maram R Aldawsari
- Department of Pharmacy, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Nujood Khaled Alturaiq
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Ali Syed
- Department of Pharmaceutical, Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alsubai
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Zeyad Kurdee
- Clinical Biochemistry Unit, Department of Pathology, College of Medicine, King Saud University, Saudi Arabia
| | - Sarah Alsubaie
- Pediatric Infectious Disease Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Manal Abouelkheir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Misr International University, Cairo, Egypt.
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Dhont E, Van Der Heggen T, Snauwaert E, Willems J, Croubels S, Delanghe J, De Waele JJ, Colman R, Vande Walle J, De Paepe P, De Cock PA. Predictors of augmented renal clearance based on iohexol plasma clearance in critically ill children. Pediatr Nephrol 2024; 39:1607-1616. [PMID: 37994980 DOI: 10.1007/s00467-023-06221-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Augmented renal clearance (ARC) holds a risk of subtherapeutic drug concentrations. Knowledge of patient-, disease-, and therapy-related factors associated with ARC would allow predicting which patients would benefit from intensified dosing regimens. This study aimed to identify ARC predictors and to describe ARC time-course in critically ill children, using iohexol plasma clearance (CLiohexol) to measure glomerular filtration rate (GFR). METHODS This is a retrospective analysis of data from the "IOHEXOL" study which validated GFR estimating formulas (eGFR) against CLiohexol. Critically ill children with normal serum creatinine were included, and CLiohexol was performed as soon as possible after pediatric intensive care unit (PICU) admission (CLiohexol1) and repeated (CLiohexol2) after 48-72 h whenever possible. ARC was defined as CLiohexol exceeding normal GFR for age plus two standard deviations. RESULTS Eighty-five patients were included; 57% were postoperative patients. Median CLiohexol1 was 122 mL/min/1.73 m2 (IQR 75-152). Forty patients (47%) expressed ARC on CLiohexol1. Major surgery other than cardiac surgery and eGFR were found as independent predictors of ARC. An eGFR cut-off value of 99 mL/min/1.73 m2 and 140 mL/min/1.73 m2 was suggested to identify ARC in children under and above 2 years, respectively. ARC showed a tendency to persist on CLiohexol2. CONCLUSIONS Our findings raise PICU clinician awareness about increased risk for ARC after major surgery and in patients with eGFR above age-specific thresholds. This knowledge enables identification of patients with an ARC risk profile who would potentially benefit from a dose increase at initiation of treatment to avoid underexposure. TRIAL REGISTRATION ClinicalTrials.gov NCT05179564, registered retrospectively on January 5, 2022.
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Affiliation(s)
- Evelyn Dhont
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | - Tatjana Van Der Heggen
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Evelien Snauwaert
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Nephrology, ERKNet Center, Ghent University Hospital, Ghent, Belgium
| | - Jef Willems
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Siska Croubels
- Department of Pathobiology, Pharmacology and Zoological Medicine, Faculty of Veterinary Medicine, Ghent University, Merelbeke, Belgium
| | - Joris Delanghe
- Department of Diagnostic Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jan J De Waele
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Nephrology, ERKNet Center, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Pieter A De Cock
- Pediatric Intensive Care Unit, Department of Intensive Care Medicine, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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6
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Wong Vega M, Starr MC, Brophy PD, Devarajan P, Soranno DE, Akcan-Arikan A, Basu R, Goldstein SL, Charlton JR, Barreto E. Advances in pediatric acute kidney injury pharmacology and nutrition: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference. Pediatr Nephrol 2024; 39:981-992. [PMID: 37878137 PMCID: PMC10817838 DOI: 10.1007/s00467-023-06178-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND In the past decade, there have been substantial advances in our understanding of pediatric AKI. Despite this progress, large gaps remain in our understanding of pharmacology and nutritional therapy in pediatric AKI. METHODS During the 26th Acute Disease Quality Initiative (ADQI) Consensus Conference, a multidisciplinary group of experts reviewed the evidence and used a modified Delphi process to achieve consensus on recommendations for gaps and advances in care for pharmacologic and nutritional management of pediatric AKI. The current evidence as well as gaps and opportunities were discussed, and recommendations were summarized. RESULTS Two consensus statements were developed. (1) High-value, kidney-eliminated medications should be selected for a detailed characterization of their pharmacokinetics, pharmacodynamics, and pharmaco-"omics" in sick children across the developmental continuum. This will allow for the optimization of real-time modeling with the goal of improving patient care. Nephrotoxin stewardship will be identified as an organizational priority and supported with necessary resources and infrastructure. (2) Patient-centered outcomes (functional status, quality of life, and optimal growth and development) must drive targeted nutritional interventions to optimize short- and long-term nutrition. Measures of acute and chronic changes of anthropometrics, body composition, physical function, and metabolic control should be incorporated into nutritional assessments. CONCLUSIONS Neonates and children have unique metabolic and growth parameters compared to adult patients. Strategic investments in multidisciplinary translational research efforts are required to fill the knowledge gaps in nutritional requirements and pharmacological best practices for children with or at risk for AKI.
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Affiliation(s)
- Molly Wong Vega
- Renal and Apheresis Services, Texas Children's Hospital, Houston, TX, USA
| | - Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Patrick D Brophy
- Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Danielle E Soranno
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Bioengineering, Purdue University, West Lafayette, IN, USA
| | - Ayse Akcan-Arikan
- Divisions of Critical Care and Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Rajit Basu
- Division of Critical Care, Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22901, USA.
| | - Erin Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
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Xu WX, Qu Q, Teng XQ, Zhuang HH, Liu SF, Wang Y, Qu J. Personalized application of antimicrobial drugs in pediatric patients with augmented renal clearance: a review of literature. Eur J Pediatr 2024; 183:51-60. [PMID: 37861791 DOI: 10.1007/s00431-023-05272-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/25/2023] [Accepted: 10/07/2023] [Indexed: 10/21/2023]
Abstract
The effect of renal functional status on drug metabolism is a crucial consideration for clinicians when determining the appropriate dosage of medications to administer. In critically ill patients, there is often a significant increase in renal function, which leads to enhanced drug metabolism and potentially inadequate drug exposure. This phenomenon, known as augmented renal clearance (ARC), is commonly observed in pediatric critical care settings. The findings of the current study underscore the significant impact of ARC on the pharmacokinetics and pharmacodynamics of antimicrobial drugs in critically ill pediatric patients. Moreover, the study reveals a negative correlation between increased creatinine clearance and blood concentrations of antimicrobial drugs. The article provides a comprehensive review of ARC screening in pediatric patients, including its definition, risk factors, and clinical outcomes. Furthermore, it summarizes the dosages and dosing regimens of commonly used antibacterial and antiviral drugs for pediatric patients with ARC, and recommendations are made for dose and infusion considerations and the role of therapeutic drug monitoring. CONCLUSION ARC impacts antimicrobial drugs in pediatric patients. WHAT IS KNOWN • ARC is inextricably linked to the failure of antimicrobial therapy, recurrence of infection, and subtherapeutic concentrations of drugs. WHAT IS NEW • This study provides an updated overview of the influence of ARC on medication use and clinical outcomes in pediatric patients. • In this context, there are several recommendations for using antibiotics in pediatric patients with ARC: 1) increase the dose administered; 2) prolonged or continuous infusion administration; 3) use of TDM; and 4) use alternative drugs that do not undergo renal elimination.
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Affiliation(s)
- Wei-Xin Xu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
- Institute of Clinical Pharmacy, Central South University, No.139 Middle Renmin Road, Changsha, 410011, People's Republic of China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, 410078, People's Republic of China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Institute of Hospital Management, Central South University, Changsha, China
- Hunan Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, 410219, China
| | - Xin-Qi Teng
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
- Institute of Clinical Pharmacy, Central South University, No.139 Middle Renmin Road, Changsha, 410011, People's Republic of China
| | - Hai-Hui Zhuang
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
- Institute of Clinical Pharmacy, Central South University, No.139 Middle Renmin Road, Changsha, 410011, People's Republic of China
| | - Si-Fan Liu
- Department of Pharmacy, Hunan Children's Hospital, Changsha, 410007, People's Republic of China
| | - Ying Wang
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China
- Institute of Clinical Pharmacy, Central South University, No.139 Middle Renmin Road, Changsha, 410011, People's Republic of China
| | - Jian Qu
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Changsha, 410011, People's Republic of China.
- Institute of Clinical Pharmacy, Central South University, No.139 Middle Renmin Road, Changsha, 410011, People's Republic of China.
- Hunan Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, 410219, China.
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Gatti M, Campoli C, Latrofa ME, Ramirez S, Sasso T, Mancini R, Caramelli F, Viale P, Pea F. Relationship Between Real-time TDM-guided Pharmacodynamic Target Attainment of Continuous Infusion Beta-lactam Monotherapy and Microbiologic Outcome in the Treatment of Critically Ill Children With Severe Documented Gram-negative Infections. Pediatr Infect Dis J 2023; 42:975-982. [PMID: 37523585 PMCID: PMC10569676 DOI: 10.1097/inf.0000000000004054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/24/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVES To explore the relationship between real-time therapeutic drug monitoring (TDM)-guided pharmacodynamic target attainment of continuous infusion (CI) beta-lactam monotherapy and microbiological outcome in the treatment of critically ill children with severe documented Gram-negative infections. METHODS Observational, monocentric, retrospective study of critically ill patients receiving CI piperacillin-tazobactam, ceftazidime, or meropenem in monotherapy for documented Gram-negative infections optimized by means of a real-time TDM-guided strategy. Average steady-state beta-lactam concentrations (C ss ) were calculated for each patient, and the beta-lactam C ss /minimum inhibitory concentration (MIC) ratio was selected as a pharmacodynamic parameter of efficacy. The C ss /MIC ratio was defined as optimal if ≥4, quasi-optimal if between 1 and 4, and suboptimal if <1. The relationship between C ss /MIC and microbiological outcome was assessed. RESULTS Forty-six TDM assessments were carried out in 21 patients [median age 2 (interquartile range: 1-8) years]. C ss /MIC ratios were optimal in 76.2% of cases. Patients with optimal C ss /MIC ratios had both a significantly higher microbiological eradication rate (75.0% vs. 0.0%; P = 0.006) and lower resistance development rate (25.0% vs. 80.0%; P = 0.047) than those with quasi-optimal or suboptimal C ss /MIC ratios. Quasi-optimal/suboptimal C ss /MIC ratio occurred more frequently when patients had infections caused by pathogens with MIC values above the European Committee on Antimicrobial Susceptibility Testing clinical breakpoint (100.0% vs. 6.3%; P < 0.001). CONCLUSIONS Real-time TDM-guided pharmacodynamic target attainment of CI beta-lactam monotherapy allowed to maximize treatment efficacy in most critically ill children with severe Gram-negative infections. Attaining early optimal C ss /MIC ratios of CI beta-lactams could be a key determinant associated with microbiologic eradication during the treatment of Gram-negative infections. Larger prospective studies are warranted for confirming our findings.
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Affiliation(s)
- Milo Gatti
- From the Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maria Elena Latrofa
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Tommaso Sasso
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Rita Mancini
- LUM Metropolitan Laboratory, AUSL Bologna, Bologna, Italy
| | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- From the Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Infectious Diseases Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- From the Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Barker CIS, Kipper K, Lonsdale DO, Wright K, Thompson G, Kim M, Turner MA, Johnston A, Sharland M, Standing JF. The Neonatal and Paediatric Pharmacokinetics of Antimicrobials study (NAPPA): investigating amoxicillin, benzylpenicillin, flucloxacillin and piperacillin pharmacokinetics from birth to adolescence. J Antimicrob Chemother 2023; 78:2148-2161. [PMID: 37531085 PMCID: PMC10477139 DOI: 10.1093/jac/dkad196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 06/09/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Pharmacokinetic (PK) data underlying paediatric penicillin dosing remain limited, especially in critical care. OBJECTIVES The primary objective of the Neonatal and Paediatric Pharmacokinetics of Antimicrobials study (NAPPA) was to characterize PK profiles of commonly used penicillins using data obtained during routine care, to further understanding of PK variability and inform future evidence-based dosing. METHODS NAPPA was a multicentre study of amoxicillin, co-amoxiclav, benzylpenicillin, flucloxacillin and piperacillin/tazobactam. Patients were recruited with informed consent. Antibiotic dosing followed standard of care. PK samples were obtained opportunistically or at optimal times, frozen and analysed using UPLC with tandem MS. Pharmacometric analysis was undertaken using NONMEM software (v7.3). Model-based simulations (n = 10 000) tested PTA with British National Formulary for Children (BNFC) and WHO dosing. The study had ethical approval. RESULTS For the combined IV PK model, 963 PK samples from 370 participants were analysed simultaneously incorporating amoxicillin, benzylpenicillin, flucloxacillin and piperacillin data. BNFC high-dose regimen simulations gave these PTA results (median fT>MIC at breakpoints of specified pathogens): amoxicillin 100% (Streptococcus pneumoniae); benzylpenicillin 100% (Group B Streptococcus); flucloxacillin 48% (MSSA); and piperacillin 100% (Pseudomonas aeruginosa). Oral population PK models for flucloxacillin and amoxicillin enabled estimation of first-order absorption rate constants (1.16 h-1 and 1.3 h-1) and bioavailability terms (62.7% and 58.7%, respectively). CONCLUSIONS NAPPA represents, to our knowledge, the largest prospective combined paediatric penicillin PK study undertaken to date, and the first paediatric flucloxacillin oral PK model. The PTA results provide evidence supportive of BNFC high-dose IV regimens for amoxicillin, benzylpenicillin and piperacillin.
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Affiliation(s)
- Charlotte I S Barker
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Department of Medical & Molecular Genetics, King’s College London, London, UK
| | - Karin Kipper
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Analytical Services International, St George’s, University of London, London, UK
- Analytical Chemistry Department, Epilepsy Society, Chesham Lane, Chalfont St Peter, Buckinghamshire, UK
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - Dagan O Lonsdale
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Kirstie Wright
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
| | - Georgina Thompson
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
| | - Min Kim
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Mark A Turner
- Department of Women’s and Children’s Health, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Atholl Johnston
- Analytical Services International, St George’s, University of London, London, UK
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Paediatric Infectious Diseases Department, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Centre for Neonatal and Paediatric Infection, Level 2 Jenner Wing, Institute for Infection and Immunity, St George’s, University of London SW17 0RE, London, UK
- Infection, Immunity and Inflammation Research & Teaching Department, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
- Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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10
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Gatti M, Pea F. The expert clinical pharmacological advice program for tailoring on real-time antimicrobial therapies with emerging TDM candidates in special populations: how the ugly duckling turned into a swan. Expert Rev Clin Pharmacol 2023; 16:1035-1051. [PMID: 37874608 DOI: 10.1080/17512433.2023.2274984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION The growing spread of infections caused by multidrug-resistant pathogens makes the need of tailoring antimicrobial therapies by means of a 'patient-centered' approach fundamental. In this scenario, therapeutic drug monitoring (TDM) of emerging antimicrobial candidates may be a valuable approach, but expert interpretation of TDM results should be granted for making them more clinically useful. The MD Clinical Pharmacologist may take over this task since this specialist may couple PK/PD expertise on drugs with a medical background and may provide expert interpretation of TDM results of antimicrobials for tailoring therapy on real-time in each single patient based on specific both drug/pathogen issues and patient issues. AREAS COVERED This article aims to highlight the main key-points and organizational aspects for implementing a successful TDM-based expert clinical pharmacological advice (ECPA) program for tailoring antimicrobial therapies on real-time in different hospitalized patient special populations. EXPERT OPINION TDM-based ECPA programs lead by the MD Clinical Pharmacologist may represent a way forward for maximizing clinical efficacy and for minimizing the risk of resistance developments and/or toxicity of antimicrobials. Stakeholders should be aware of the fact that this innovative approach may be cost-effective.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
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11
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Li Z, Qi B, Yuan Y, Liu H. Vancomycin is under-blood concentration in critically ill children: A case report. Asian J Surg 2023:S1015-9584(23)00348-2. [PMID: 36948949 DOI: 10.1016/j.asjsur.2023.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 03/08/2023] [Indexed: 03/24/2023] Open
Affiliation(s)
- Zhuo Li
- The First Clinical Medical College, Gansu University of Chinese Medicine (Gansu Provincial Hospital), Lanzhou, China
| | - Baoli Qi
- The First Clinical Medical College, Gansu University of Chinese Medicine (Gansu Provincial Hospital), Lanzhou, China
| | - Yuan Yuan
- First Department of Critical Care Medicine, Gansu Provincial Hospital, Lanzhou, China
| | - Hua Liu
- The First Clinical Medical College, Gansu University of Chinese Medicine (Gansu Provincial Hospital), Lanzhou, China; Department of Respiratory and Critical Care Medicine, Gansu Provincial Hospital, Lanzhou, China.
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12
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Debray A, Callot D, Hirt D, Bille E, Renolleau S, Chouchana L, Tréluyer JM, Oualha M, Béranger A. Beta-lactam exposure and safety in intermittent or continuous infusion in critically ill children: an observational monocenter study. Eur J Pediatr 2023; 182:965-973. [PMID: 36422708 DOI: 10.1007/s00431-022-04716-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022]
Abstract
The aim of this study was to assess the pharmacokinetic (PK) exposure and clinical toxicity for three beta-lactams: cefotaxime, piperacillin/tazobactam, and meropenem, depending on two lengths of infusion: continuous and intermittent, in critically ill children. This single center observational prospective study was conducted in a pediatric intensive care unit. All hospitalized children who had one measured plasma concentration of the investigated antibiotics were included. Plasma antibiotic concentrations were interpreted by a pharmacologist, using a Bayesian approach based on previously published population pharmacokinetic models in critically ill children. Exposure was considered optimal, low, or high according to the PK target 100% fT> 4 × MIC and a trough concentration below the toxic concentration (50 mg.L-1 for cefotaxime, 150 mg.L-1 for piperacillin, and 44 mg.L-1 for meropenem). Between May 2019 and January 2020, 80 patients were included and received 106 antibiotic courses: 74 (70%) were administered in intermittent infusion (II) and 32 (30%) in continuous infusion (CI). Compared to II, CI provided more optimal PK exposure (n = 22/32, 69% for CI versus n = 35/74, 47% for II, OR 1.2, 95%CI 1.01-1.5, p = 0.04), less underexposure (n = 4/32, 13% for CI versus n = 36/74, 49% for II, OR 0.7, 95%CI 0.6-0.84, p < 0.001), and more overexposure (n = 6/32, 19% for CI versus n = 3/74, 4% for II, OR 1.2, 95%CI 1.03-1.3, p = 0.01). Five adverse events have been reported during the study period, although none has been attributed to beta-lactam treatment. CONCLUSION CI provided a higher probability to attain an optimal PK target compared to II, but also a higher risk for overexposure. Regular therapeutic drug monitoring is recommended in critically ill children receiving beta-lactams, regardless of the length of infusion. WHAT IS KNOWN • Since beta-lactams are time-dependent antibiotics, the probability to attain the pharmacokinetic target is higher with continuous infusion compared to that with intermittent infusion. • In daily practice, continuous or extended infusions are rarely used despite recent guidelines, and toxicity is hardly reported. WHAT IS NEW • Continuous infusion provided a higher probability to attain an optimal pharmacokinetic target compared to intermittent infusion, but also a higher risk of overexposure. • Regular therapeutic drug monitoring is recommended in critically ill children receiving beta-lactams, regardless of the length of infusion.
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Affiliation(s)
- Agathe Debray
- Pédiatrie Générale Et Maladies Infectieuses, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France
| | - Delphine Callot
- Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Pharmacovigilance, Paris, France
- Pharmacologie Et Évaluations Thérapeutiques Chez L'enfant Et La Femme Enceinte, EA7323, Paris, France
| | - Déborah Hirt
- Pharmacologie Et Évaluations Thérapeutiques Chez L'enfant Et La Femme Enceinte, EA7323, Paris, France
- Service de Pharmacologie Clinique, Hôpital Cochin, AP-HP, Paris, France
| | - Emmanuelle Bille
- Laboratoire de Microbiologie, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Paris, France
| | - Sylvain Renolleau
- Réanimation Et Surveillance Continue Médico-Chirurgicales Pédiatriques, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, 149 Rue de Sèvres, 75015, Paris, France
| | - Laurent Chouchana
- Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, Pharmacovigilance, Paris, France
- Pharmacologie Et Évaluations Thérapeutiques Chez L'enfant Et La Femme Enceinte, EA7323, Paris, France
| | - Jean-Marc Tréluyer
- Pharmacologie Et Évaluations Thérapeutiques Chez L'enfant Et La Femme Enceinte, EA7323, Paris, France
- Service de Pharmacologie Clinique, Hôpital Cochin, AP-HP, Paris, France
- Unité de Recherche Clinique - Centre d'Investigation Clinique 1419, Hôpital Cochin-Necker, Université de Paris, Inserm, Paris, France
| | - Mehdi Oualha
- Pharmacologie Et Évaluations Thérapeutiques Chez L'enfant Et La Femme Enceinte, EA7323, Paris, France
- Réanimation Et Surveillance Continue Médico-Chirurgicales Pédiatriques, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, 149 Rue de Sèvres, 75015, Paris, France
| | - Agathe Béranger
- Pharmacologie Et Évaluations Thérapeutiques Chez L'enfant Et La Femme Enceinte, EA7323, Paris, France.
- Réanimation Et Surveillance Continue Médico-Chirurgicales Pédiatriques, Hôpital Necker-Enfants Malades, AP-HP, Université de Paris, 149 Rue de Sèvres, 75015, Paris, France.
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13
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Glomerular filtration rate in critically ill neonates and children: creatinine-based estimations versus iohexol-based measurements. Pediatr Nephrol 2023; 38:1087-1097. [PMID: 35916956 PMCID: PMC9925555 DOI: 10.1007/s00467-022-05651-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/11/2022] [Accepted: 06/01/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) and augmented renal clearance (ARC), both alterations of the glomerular filtration rate (GFR), are prevalent in critically ill children and neonates. AKI and ARC prevalence estimates are based on estimation of GFR (eGFR) using serum creatinine (SCr), which is known to be inaccurate. We aimed to test our hypothesis that AKI prevalence will be higher and ARC prevalence will be lower in critically ill children when using iohexol-based measured GFR (mGFR), rather than using eGFR. Additionally, we aimed to investigate the performance of different SCr-based eGFR methods. METHODS In this single-center prospective study, critically ill term-born neonates and children were included. mGFR was calculated using a plasma disappearance curve after parenteral administration of iohexol. AKI diagnosis was based on the KDIGO criteria, SCr-based eGFR, and creatinine clearance (CrCL). Differences between eGFR and mGFR were determined using Wilcoxon signed-rank tests and by calculating bias and accuracy (percentage of eGFR values within 30% of mGFR values). RESULTS One hundred five children, including 43 neonates, were included. AKI prevalence was higher based on mGFR (48%), than with KDIGO or eGFR (11-40%). ARC prevalence was lower with mGFR (24%) compared to eGFR (38-51%). eGFR equations significantly overestimated mGFR (60-71 versus 41 ml/min/1.73 m2, p < 0.001-0.002). Accuracy was highest with eGFR equations based on age- and sex-dependent equations (up to 59%). CONCLUSION Iohexol-based AKI prevalence was higher and ARC prevalence lower compared to standard SCr-based eGFR methods. Age- and sex-dependent equations for eGFR (eGFR-Smeets for neonates and eGFR-Pierce for children) best approached measured GFR and should preferably be used to optimize diagnosis of AKI and ARC in this population. A higher resolution version of the Graphical abstract is available as Supplementary information.
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14
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Therapeutic monitoring of serum concentrations of acyclovir and its metabolite 9-(carboxymethoxymethyl) guanine in routine clinical practice. Biomed Pharmacother 2022; 156:113852. [DOI: 10.1016/j.biopha.2022.113852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
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15
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Tang Girdwood S, Pavia K, Paice K, Hambrick HR, Kaplan J, Vinks AA. β-lactam precision dosing in critically ill children: Current state and knowledge gaps. Front Pharmacol 2022; 13:1044683. [PMID: 36532752 PMCID: PMC9752101 DOI: 10.3389/fphar.2022.1044683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022] Open
Abstract
There has been emerging interest in implementing therapeutic drug monitoring and model-informed precision dosing of β-lactam antibiotics in critically ill patients, including children. Despite a position paper endorsed by multiple international societies that support these efforts in critically ill adults, implementation of β-lactam precision dosing has not been widely adopted. In this review, we highlight what is known about β-lactam antibiotic pharmacokinetics and pharmacodynamics in critically ill children. We also define the knowledge gaps that present barriers to acceptance and implementation of precision dosing of β-lactam antibiotics in critically ill children: a lack of consensus on which subpopulations would benefit most from precision dosing and the uncertainty of how precision dosing changes outcomes. We conclude with opportunities for further research to close these knowledge gaps.
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Affiliation(s)
- Sonya Tang Girdwood
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,*Correspondence: Sonya Tang Girdwood,
| | - Kathryn Pavia
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Kelli Paice
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - H. Rhodes Hambrick
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Jennifer Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States,Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Alexander A. Vinks
- Division of Clinical Pharmacology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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16
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Smits A, Annaert P, Cavallaro G, De Cock PAJG, de Wildt SN, Kindblom JM, Lagler FB, Moreno C, Pokorna P, Schreuder MF, Standing JF, Turner MA, Vitiello B, Zhao W, Weingberg AM, Willmann R, van den Anker J, Allegaert K. Current knowledge, challenges and innovations in developmental pharmacology: A combined conect4children Expert Group and European Society for Developmental, Perinatal and Paediatric Pharmacology White Paper. Br J Clin Pharmacol 2022; 88:4965-4984. [PMID: 34180088 PMCID: PMC9787161 DOI: 10.1111/bcp.14958] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/22/2021] [Accepted: 05/30/2021] [Indexed: 12/30/2022] Open
Abstract
Developmental pharmacology describes the impact of maturation on drug disposition (pharmacokinetics, PK) and drug effects (pharmacodynamics, PD) throughout the paediatric age range. This paper, written by a multidisciplinary group of experts, summarizes current knowledge, and provides suggestions to pharmaceutical companies, regulatory agencies and academicians on how to incorporate the latest knowledge regarding developmental pharmacology and innovative techniques into neonatal and paediatric drug development. Biological aspects of drug absorption, distribution, metabolism and excretion throughout development are summarized. Although this area made enormous progress during the last two decades, remaining knowledge gaps were identified. Minimal risk and burden designs allow for optimally informative but minimally invasive PK sampling, while concomitant profiling of drug metabolites may provide additional insight in the unique PK behaviour in children. Furthermore, developmental PD needs to be considered during drug development, which is illustrated by disease- and/or target organ-specific examples. Identifying and testing PD targets and effects in special populations, and application of age- and/or population-specific assessment tools are discussed. Drug development plans also need to incorporate innovative techniques such as preclinical models to study therapeutic strategies, and shift from sequential enrolment of subgroups, to more rational designs. To stimulate appropriate research plans, illustrations of specific PK/PD-related as well as drug safety-related challenges during drug development are provided. The suggestions made in this joint paper of the Innovative Medicines Initiative conect4children Expert group on Developmental Pharmacology and the European Society for Developmental, Perinatal and Paediatric Pharmacology, should facilitate all those involved in drug development.
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Affiliation(s)
- Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal intensive Care unit, University Hospitals Leuven, Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Giacomo Cavallaro
- Neonatal intensive care unit, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan, Italy
| | - Pieter A J G De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium.,Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium.,Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Saskia N de Wildt
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology and Toxicology, Radboud Institute Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jenny M Kindblom
- Pediatric Clinical Research Center, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Florian B Lagler
- Institute for Inherited Metabolic Diseases and Department of Pediatrics, Paracelsus Medical University, Clinical Research Center Salzburg, Salzburg, Austria
| | - Carmen Moreno
- Institute of Psychiatry and Mental Health, Child and Adolescent Psychiatry Department, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, CIBERSAM, Madrid, Spain
| | - Paula Pokorna
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Department of Physiology and Pharmacology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Joseph F Standing
- UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Mark A Turner
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool Health Partners, Liverpool, UK
| | - Benedetto Vitiello
- Division of Child and Adolescent Neuropsychiatry, Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, China.,Department of Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China.,Clinical Research Centre, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | | | | | - John van den Anker
- Intensive Care and Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Dhont E, Windels C, Snauwaert E, Van Der Heggen T, de Jaeger A, Dhondt L, Delanghe J, Croubels S, Walle JV, De Paepe P, De Cock PA. Reliability of glomerular filtration rate estimating formulas compared to iohexol plasma clearance in critically ill children. Eur J Pediatr 2022; 181:3851-3866. [PMID: 36053381 DOI: 10.1007/s00431-022-04570-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/14/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
UNLABELLED Accurate renal function assessment is crucial to guide intensive care decision-making and drug dosing. Estimates of glomerular filtration rate (eGFR) are routinely used in critically ill children; however, these formulas were never evaluated against measured GFR (mGFR) in this population. We aimed to assess the reliability of common eGFR formulas compared to iohexol plasma clearance (CLiohexol) in a pediatric intensive care (PICU) population. Secondary outcomes were the prevalence of acute kidney injury (AKI) (by pRIFLE criteria) and augmented renal clearance (ARC) (defined as standard GFR for age + 2 standard deviations (SD)) within 48 h after admission based on mGFR and eGFR by the revised Schwartz formula and the difference between these two methods to diagnose AKI and ARC. In children, between 0 and 15 years of age, without chronic renal disease, GFR was measured by CLiohexol and estimated using 26 formulas based on creatinine (Scr), cystatine C (CysC), and betatrace protein (BTP), early after PICU admission. eGFR and mGFR results were compared for the entire study population and in subgroups according to age, using Bland-Altman analysis with calculation of bias, precision, and accuracy expressed as percentage of eGFR results within 30% (P30) and 10% (P10) of mGFR. CLiohexol was measured in 98 patients. Mean CLiohexol (± SD) was 115 ± 54 ml/min/1.73m2. Most eGFR formulas showed overestimation of mGFR with large bias and poor precision reflected by wide limits of agreement (LoA). Bias was larger with CysC- and BTP-based formulas compared to Scr-based formulas. In the entire study population, none of the eGFR formulas showed the minimal desired P30 > 75%. The widely used revised Schwartz formula overestimated mGFR with a high percentage bias of - 18 ± 51% (95% confidence interval (CI) - 29; - 9), poor precision with 95% LoA from - 120 to 84% and insufficient accuracy reflected by P30 of only 51% (95% CI 41; 61), and P10 of 21% (95% CI 13; 66) in the overall population. Although performance of Scr-based formulas was worst in children below 1 month of age, exclusion of neonates and younger children did not result in improved agreement and accuracy. Based on mGFR, prevalence of AKI and ARC within 48 h was 17% and 45% of patients, respectively. There was poor agreement between revised Schwartz formula and mGFR to diagnose AKI (kappa value of 0.342, p < 0.001; sensitivity of 30%, 95% CI 5; 20%) and ARC (kappa value of 0.342, p < 0.001; sensitivity of 70%, 95% CI 33; 58). CONCLUSION In this proof-of-concept study, eGFR formulas were found to be largely inaccurate in the PICU population. Clinicians should therefore use these formulas with caution to guide drug dosing and therapeutic interventions in critically ill children. More research in subgroup populations is warranted to conclude on generalizability of these study findings. CLINICALTRIALS gov NCT05179564, registered retrospectively on January 5, 2022. WHAT IS KNOWN • Both acute kidney injury and augmented renal clearance may be present in PICU patients and warrant adaptation of therapy, including drug dosing. • Biomarker-based eGFR formulas are widely used for GFR assessment in critically ill children, although endogenous filtration biomarkers have important limitations in PICU patients and eGFR formulas have never been validated against measured GFR in this population. WHAT IS NEW • eGFR formulas were found to be largely inaccurate in the PICU population when compared to measured GFR by iohexol clearance. Clinicians should therefore use these formulas with caution to guide drug dosing and therapeutic interventions in critically ill children. • Iohexol plasma clearance could be considered an alternative for accurate GFR assessment in PICU patients.
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Affiliation(s)
- Evelyn Dhont
- Department of Pediatric Intensive Care, Pediatric Intensive Care 1K12D, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium.
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium.
| | - Charlotte Windels
- Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium
| | - Evelien Snauwaert
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Tatjana Van Der Heggen
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
| | - Annick de Jaeger
- Department of Pediatric Intensive Care, Pediatric Intensive Care 1K12D, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Laura Dhondt
- Faculty of Veterinary Medicine, Department of Pathobiology, Pharmacology and Zoological Medicine, Ghent University, Ghent, Belgium
| | - Joris Delanghe
- Faculty of Medicine and Health Sciences, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Siska Croubels
- Faculty of Veterinary Medicine, Department of Pathobiology, Pharmacology and Zoological Medicine, Ghent University, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Pieter A De Cock
- Department of Pediatric Intensive Care, Pediatric Intensive Care 1K12D, Ghent University Hospital, C. Heymanslaan 10, 9000, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
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18
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Abstract
OBJECTIVES In critically ill children, severely altered pharmacokinetics may result in subtherapeutic β-lactam antibiotic concentrations when standard pediatric dosing regimens are applied. However, it remains unclear how to recognize patients most at risk for suboptimal exposure and their outcome. This study aimed to: 1) describe target attainment for β-lactam antibiotics in critically ill children, 2) identify risk factors for suboptimal exposure, and 3) study the association between target nonattainment and clinical outcome. DESIGN Post hoc analysis of the "Antibiotic Dosing in Pediatric Intensive Care" study (NCT02456974, 2012-2019). Steady-state trough plasma concentrations were classified as therapeutic if greater than or equal to the minimum inhibitory concentration of the (suspected) pathogen. Factors associated with subtherapeutic concentrations and clinical outcome were identified by logistic regression analysis. SETTING The pediatric and cardiac surgery ICU of a Belgian tertiary-care hospital. PATIENTS One hundred fifty-seven patients (aged 1 mo to 15 yr) treated intravenously with amoxicillin-clavulanic acid, piperacillin-tazobactam, or meropenem. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three hundred eighty-two trough concentrations were obtained from 157 patients (median age, 1.25 yr; interquartile range, 0.4-4.2 yr). Subtherapeutic concentrations were measured in 39 of 60 (65%), 43 of 48 (90%), and 35 of 49 (71%) of patients treated with amoxicillin-clavulanic acid, piperacillin-tazobactam, and meropenem, respectively. Estimates of glomerular filtration rate (eGFR; 54% increase in odds for each sd increase in value, 95% CI, 0.287-0.736; p = 0.001) and the absence of vasopressor treatment (2.8-fold greater odds, 95% CI, 1.079-7.253; p = 0.034) were independently associated with target nonattainment. We failed to identify an association between antibiotic concentrations and clinical failure. CONCLUSIONS Subtherapeutic β-lactam concentrations are common in critically ill children and correlate with renal function. eGFR equations may be helpful in identifying patients who may require higher dosing. Future studies should focus on the impact of subtherapeutic concentrations on clinical outcome.
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19
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Guerra Valero YC, Dorofaeff T, Coulthard MG, Sparkes L, Lipman J, Wallis SC, Roberts JA, Parker SL. Optimal dosing of cefotaxime and desacetylcefotaxime for critically ill paediatric patients. Can we use microsampling? J Antimicrob Chemother 2022; 77:2227-2237. [PMID: 35678266 PMCID: PMC9333413 DOI: 10.1093/jac/dkac168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To describe the population pharmacokinetics of cefotaxime and desacetylcefotaxime in critically ill paediatric patients and provide dosing recommendations. We also sought to evaluate the use of capillary microsampling to facilitate data-rich blood sampling. Methods Patients were recruited into a pharmacokinetic study, with cefotaxime and desacetylcefotaxime concentrations from plasma samples collected at 0, 0.5, 2, 4 and 6 h used to develop a population pharmacokinetic model using Pmetrics. Monte Carlo dosing simulations were tested using a range of estimated glomerular filtration rates (60, 100, 170 and 200 mL/min/1.73 m2) and body weights (4, 10, 15, 20 and 40 kg) to achieve pharmacokinetic/pharmacodynamic (PK/PD) targets, including 100% ƒT>MIC with an MIC breakpoint of 1 mg/L. Results Thirty-six patients (0.2–12 years) provided 160 conventional samples for inclusion in the model. The pharmacokinetics of cefotaxime and desacetylcefotaxime were best described using one-compartmental model with first-order elimination. The clearance and volume of distribution for cefotaxime were 12.8 L/h and 39.4 L, respectively. The clearance for desacetylcefotaxime was 10.5 L/h. Standard dosing of 50 mg/kg q6h was only able to achieve the PK/PD target of 100% ƒT>MIC in patients >10 kg and with impaired renal function or patients of 40 kg with normal renal function. Conclusions Dosing recommendations support the use of extended or continuous infusion to achieve cefotaxime exposure suitable for bacterial killing in critically ill paediatric patients, including those with severe or deep-seated infection. An external validation of capillary microsampling demonstrated skin-prick sampling can facilitate data-rich pharmacokinetic studies.
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Affiliation(s)
| | - Tavey Dorofaeff
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
| | - Mark G Coulthard
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia.,Mayne Academy of Paediatrics, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Louise Sparkes
- Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Jamieson Trauma Institute, Royal Brisbane & Women's Hospital, Herston, QLD 4029, Australia
| | - Steven C Wallis
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
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20
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Al-Eyadhy A, Al-Jelaify MR. Suboptimal vancomycin levels in critically ill children with sickle cell disease and acute chest syndrome. J Infect Chemother 2022; 28:1304-1309. [DOI: 10.1016/j.jiac.2022.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/24/2022] [Accepted: 05/29/2022] [Indexed: 10/18/2022]
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21
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Chuphan C, Sukarnjanaset W, Puthanakit T, Wattanavijitkul T. Population Pharmacokinetics and Pharmacodynamics of Vancomycin in Pediatric Patients With Various Degrees of Renal Function. J Pediatr Pharmacol Ther 2022; 27:419-427. [DOI: 10.5863/1551-6776-27.5.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Although vancomycin dosage recommendations in the pediatric setting for methicillin-resistant Staphylococcus aureus (MRSA) infection indicate that ≥60 mg/kg/day is correlated to a desired area under the vancomycin concentration time curve from 0 to 24 hours to minimum inhibitory concentration ratio (AUC0–24 hr/MIC) ≥400, for some patients this dosage is inadequate or relates to toxicity. This study purposed to explore vancomycin dosing for pediatrics with various degrees of renal function.
METHODS
Routine monitoring data were retrospectively collected from patients, aged 1 month to 18 years. Population pharmacokinetic analysis was performed by using non-linear mixed-effect model with NONMEM software, and Monte Carlo simulation was conducted by using Crystal Ball software.
RESULTS
Two hundred twelve patients with 348 vancomycin serum concentrations were included. Median age was 3.5 years (IQR, 0.9–10.9), median weight was 14.0 kg (IQR, 7.2–30.4), with baseline estimated glomerular filtration rate (eGFR) ranging from 15.5 to 359.3 mL/min/1.73 m2. A 1-compartment model with first-order elimination sufficiently described vancomycin PK. The dosing targeting AUC0–24hr/MIC ≥400 and AUC0–24hr <800 mg•h/L for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2 was 12.5, 25, 40, 60, and 70 mg/kg/day, respectively. All vancomycin dosing obtained >85% of the cumulative fraction of response across the MIC distribution of MRSA.
CONCLUSIONS
Vancomycin dosing of 12.5, 25, 40, 60, and 70 mg/kg/day is suggested for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2, respectively.
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Affiliation(s)
- Chanika Chuphan
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanyawee Puthanakit
- Department of Pediatrics (TP), Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thitima Wattanavijitkul
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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22
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Maimongkol P, Yonwises W, Anugulruengkitt S, Sophonphan J, Treyaprasert W, Wacharachaisurapol N. Therapeutic drug monitoring of meropenem and pharmacokinetic-pharmacodynamic target assessment in critically ill pediatric patients from a prospective observational study. Int J Infect Dis 2022; 120:96-102. [PMID: 35489632 DOI: 10.1016/j.ijid.2022.04.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES To compare the unbound plasma meropenem concentrations at mid-dosing intervals (Cmid, 50%fT), end-dosing intervals (Ctrough, 100%fT), and proportions of patients achieving 50%fT and 100%fT above MIC (50%fT>MIC and 100%fT>MIC) between extended infusion (EI) and intermittent bolus (IB) administration in a therapeutic drug monitoring (TDM) program in children. METHODS A prospective observational study was conducted in children aged 1 month to 18 years receiving meropenem every 8 h by either EI or IB. Meropenem Cmid, Ctrough, and proportions of patients achieving 50%fT>MIC and 100%fT>MIC were compared. RESULTS TDM data from 72 patients with a median age (IQR) of 12 months (3-37) were used. Meropenem dose was 120 and 60 mg/kg/day in EI and IB groups, respectively. Geometric mean (95% CI) Cmid of EI versus IB was 17.3 mg/L (13.7-21.8) versus 3.4 mg/L (1.7-6.7) (P<0.001). Geometric mean (95% CI) Ctrough of EI versus IB was 2.3 mg/L (1.6-3.4) versus 0.8 mg/L (0.4-1.5) (P=0.005). Greater proportions of patients achieving 50%fT>MIC and 100%fT>MIC were observed in the EI group. CONCLUSIONS A meropenem dose of 20 mg/kg/dose given by IB should not be used in critically ill children, even if they are not suspected of having a CNS infection. A dose of 40 mg/kg/dose given by EI resulted in higher Cmid, Ctrough, and proportions of patients achieving 50%fT>MIC and 100%fT>MIC.
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Affiliation(s)
- Passara Maimongkol
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wanlika Yonwises
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jiratchaya Sophonphan
- The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT), Bangkok, Thailand
| | - Wanchai Treyaprasert
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Noppadol Wacharachaisurapol
- Clinical Pharmacokinetics and Pharmacogenomics Research Unit, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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23
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Butragueño-Laiseca L, Marco-Ariño N, Troconiz IF, Grau S, Campillo N, García X, Padilla B, Fernández SN, Slöcker M, Santiago MJ. Population pharmacokinetics of piperacillin in critically ill children including those undergoing continuous kidney replacement therapy. Clin Microbiol Infect 2022; 28:1287.e9-1287.e15. [PMID: 35390523 DOI: 10.1016/j.cmi.2022.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/09/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Despite that piperacillin-tazobactam combination is commonly used in critically ill children, increasing evidence suggests that the current dosing schedules are not optimal for these patients. The aim of this work is to develop a population pharmacokinetic (PK) model for piperacillin to evaluate the efficacy of standard dosing in children with and without kidney replacement therapy (CKRT), and to propose alternative dosing schemes maximizing target attainment. METHODS 429 piperacillin concentrations measured in different matrices, obtained from 32 critically ill children (19 without CKRT, 13 with CKRT) receiving 100 mg/kg of piperacillin/tazobactam every 8 hours (increased to 12h after the 4th dose) were modelled simultaneously using the population approach with NONMEM 7.4. The percentage of patients with 90% fT>MIC and target attainment (percentage of dosing interval above MIC) were estimated for different intermittent and continuous infusions in the studied population. RESULTS Piperacillin PK was best described with a two-compartment model. Renal (CLR), nonrenal (CLM), and hemofilter (CLCKRT) clearances were found to be influenced by the glomerular filtration rate, height (CLR), weight (CLM) and filter surface (CLCKRT). Only 7 (37%) children without CKRT and 7 (54%) with CKRT achieved 90% fT >MIC with the current dosing schedule. Of the alternative regimens evaluated, a 24h continuous infusion of 200 mg/kg (CKRT) and 300 mg/kg (no CKRT) provided 100% fT >MIC(≤16mg/L) and target attainments ≥90% across all evaluated MICs. CONCLUSIONS In children with and without CKRT, standard dosing failed to provide an adequate systemic exposure, while prolonged and continuous infusions showed an improved efficacy.
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Affiliation(s)
- Laura Butragueño-Laiseca
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Nicolás Marco-Ariño
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Iñaki F Troconiz
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona Barcelona, Spain
| | - Nuria Campillo
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona Barcelona, Spain
| | - Xandra García
- Pharmacy Department, Hospital General Universitario Gregorio Marañón
| | - Belén Padilla
- Clinical Microbiology Department, Hospital General Universitario Gregorio Marañón
| | - Sarah Nicole Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María Slöcker
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain.
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24
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Mantelli MI, Roques BB, Blanchard TA, Mounier M, Quincey M, Jolivet FB, Jousserand NP, Marchand A, Diquélou AN, Reynolds BS, Coyne M, Trumel C, Lefebvre HP, Concordet D, Lavoué R. Short course of immune-suppressive doses of prednisolone, evaluated through a prospective double-masked placebo-controlled clinical trial in healthy Beagles, is associated with sustained modifications in renal, hydration, and electrolytic status. Am J Vet Res 2022; 83:434-442. [PMID: 35175932 DOI: 10.2460/ajvr.21.09.0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the effects and duration of orally administered prednisolone on renal function evaluated by glomerular filtration rate (GFR) determination and creatinine (Cr) and symmetric dimethylarginine (SDMA) concentrations as well as on urinalysis, electrolytes, and hydric status in healthy dogs. ANIMALS 14 healthy Beagles. PROCEDURES In this prospective double-masked placebo-controlled study, dogs were randomized after baseline evaluation to receive a 7-day course of either prednisolone (1.5 to 2.0 mg/kg, PO, q 12 h) or a placebo. A repeated-measure design was performed, each dog participating in 4 successive sampling sessions. Clinical data, systolic blood pressure, CBC, and biochemical analyses including serum SDMA concentration, GFR determination, urine output quantification, and complete urinalysis were performed for all dogs the day before (D0) and at the end of steroid administration (D7) as well as 2 weeks (D21) and 4 weeks (D35) after the end of treatment. RESULTS At D7, when compared with baseline, GFR increased significantly in treated dogs, whereas creatinine and SDMA concentrations decreased significantly. GFR and Cr but not SDMA modifications persisted significantly at D21. None of the variables differed significantly from baseline at D35. The OR of presenting an albumin band on urine electrophoresis was 2.4 times as high in treated versus control dogs (OR, 36; 95% CI, 1.8 to 719.4; P = 0.02). CLINICAL RELEVANCE A short-term course of immune-suppressive prednisolone treatment in healthy dogs leads to a sustained but reversible renal hyperfiltration state. Modification in electrolytic variables can affect the clinical interpretation of blood work in such patients.
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Affiliation(s)
- M I Mantelli
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - B B Roques
- Department of Physiology & Therapeutics, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France.,Innovations thérapeutiques et résistances, Université de Toulouse, Institut national de recherche pour l'agriculture, l'alimentation et l'environnement, Ecole Nationale Vétérinaire de Toulouse, Université Paul-Sabatier, Toulouse, France
| | - T A Blanchard
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - M Mounier
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - M Quincey
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - F B Jolivet
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - N P Jousserand
- Institut de recherche en santé digestive, Université de Toulouse, INSERM, Institut national de recherche pour l'agriculture, Ecole Nationale Vétérinaire de Toulouse, Université Paul-Sabatier, Toulouse, France
| | - A Marchand
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - A N Diquélou
- Institut de recherche en santé digestive, Université de Toulouse, INSERM, Institut national de recherche pour l'agriculture, Ecole Nationale Vétérinaire de Toulouse, Université Paul-Sabatier, Toulouse, France
| | - B S Reynolds
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - M Coyne
- Idexx Laboratories Inc, Westbrook, ME
| | - C Trumel
- Laboratoire Central de Biologie Médicale, Centre Régional d'Exploration Fonctionnelle et de Ressources Expérimentales, Université de Toulouse, Université Paul-Sabatier, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - H P Lefebvre
- Department of Clinical Sciences, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France.,Department of Physiology & Therapeutics, Université de Toulouse, Ecole Nationale Vétérinaire de Toulouse, Toulouse, France
| | - D Concordet
- Innovations thérapeutiques et résistances, Université de Toulouse, Institut national de recherche pour l'agriculture, l'alimentation et l'environnement, Ecole Nationale Vétérinaire de Toulouse, Université Paul-Sabatier, Toulouse, France
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25
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Bruns N, Dohna-Schwake C. Antibiotics in critically ill children-a narrative review on different aspects of a rational approach. Pediatr Res 2022; 91:440-446. [PMID: 34873285 PMCID: PMC8816725 DOI: 10.1038/s41390-021-01878-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 12/19/2022]
Abstract
Especially critically ill children are exposed to antibiotic overtreatment, mainly caused by the fear of missing out a severe bacterial infection. Potential adverse effects and selection of multi-drug resistant bacteria play minor roles in decision making. This narrative review first describes harm from antibiotics and second focuses on different aspects that could help to reduce antibiotic overtreatment without harming the patient: harm from antibiotic treatment, diagnostic approaches, role of biomarkers, timing of antibiotic therapy, empiric therapy, targeted therapy, and therapeutic drug monitoring. Wherever possible, we linked the described evidence to the current Surviving Sepsis Campaign guidelines. Antibiotic stewardship programs should help guiding antibiotic therapy for critically ill children. IMPACT: Critically ill children can be harmed by inadequate or overuse of antibiotics. Hemodynamically unstable children with a suspicion of infection should be immediately treated with broad-spectrum antibiotics. In contrast, in hemodynamically stable children with sepsis and organ dysfunction, a time frame of 3 h for proper diagnostics may be adequate before starting antibiotics if necessary. Less and more targeted antibiotic treatment can be achieved via antibiotic stewardship programs.
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Affiliation(s)
- Nora Bruns
- grid.5718.b0000 0001 2187 5445Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany. .,Westdeutsches Zentrum für Infektiologie, University of Duisburg-Essen, Essen, Germany.
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26
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Gatti M, Cojutti PG, Campoli C, Caramelli F, Corvaglia LT, Lanari M, Pession A, Ramirez S, Viale P, Pea F. A Proof of Concept of the Role of TDM-Based Clinical Pharmacological Advices in Optimizing Antimicrobial Therapy on Real-Time in Different Paediatric Settings. Front Pharmacol 2021; 12:755075. [PMID: 34646143 PMCID: PMC8502823 DOI: 10.3389/fphar.2021.755075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 09/13/2021] [Indexed: 01/14/2023] Open
Abstract
Introduction: Antimicrobial treatment is quite common among hospitalized children. The dynamic age-associated physiological variations coupled with the pathophysiological alterations caused by underlying illness and potential drug-drug interactions makes the implementation of appropriate antimicrobial dosing extremely challenging among paediatrics. Therapeutic drug monitoring (TDM) may represent a valuable tool for assisting clinicians in optimizing antimicrobial exposure. Clinical pharmacological advice (CPA) is an approach based on the correct interpretation of the TDM result by the MD Clinical Pharmacologist in relation to specific underlying conditions, namely the antimicrobial susceptibility of the clinical isolate, the site of infection, the pathophysiological characteristics of the patient and/or the drug-drug interactions of cotreatments. The aim of this study was to assess the role of TDM-based CPAs in providing useful recommendations for the real-time personalization of antimicrobial dosing regimens in various paediatric settings. Materials and methods: Paediatric patients who were admitted to different settings of the IRCCS Azienda Ospedaliero-Universitaria of Bologna, Italy (paediatric intensive care unit [ICU], paediatric onco-haematology, neonatology, and emergency paediatric ward), between January 2021 and June 2021 and who received TDM-based CPAs on real-time for personalization of antimicrobial therapy were retrospectively assessed. Demographic and clinical features, CPAs delivered in relation to different settings and antimicrobials, and type of dosing adjustments were extracted. Two indicators of performance were identified. The number of dosing adjustments provided over the total number of delivered CPAs. The turnaround time (TAT) of CPAs according to a predefined scale (optimal, <12 h; quasi-optimal, between 12-24 h; acceptable, between 24-48 h; suboptimal, >48 h). Results: Overall, 247 CPAs were delivered to 53 paediatric patients (mean 4.7 ± 3.7 CPAs/patient). Most were delivered to onco-haematological patients (39.6%) and to ICU patients (35.8%), and concerned mainly isavuconazole (19.0%) and voriconazole (17.8%). Overall, CPAs suggested dosing adjustments in 37.7% of cases (24.3% increases and 13.4% decreases). Median TAT was 7.5 h (IQR 6.1-8.8 h). Overall, CPAs TAT was optimal in 91.5% of cases, and suboptimal in only 0.8% of cases. Discussion: Our study provides a proof of concept of the helpful role that TDM-based real-time CPAs may have in optimizing antimicrobial exposure in different challenging paediatric scenarios.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pier Giorgio Cojutti
- SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Campoli
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luigi Tommaso Corvaglia
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marcello Lanari
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Pession
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Pediatric Oncology & Hematology Unit 'Lalla Seràgnoli', IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy.,SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine. Antibiotics (Basel) 2021; 10:antibiotics10101182. [PMID: 34680763 PMCID: PMC8532953 DOI: 10.3390/antibiotics10101182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.
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Rhoney DH, Metzger SA, Nelson NR. Scoping review of augmented renal clearance in critically ill pediatric patients. Pharmacotherapy 2021; 41:851-863. [PMID: 34431121 DOI: 10.1002/phar.2617] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
Augmented renal clearance (ARC), a phenomenon of enhanced elimination of renal solutes, has been described in adult critically ill patients, but little is known about the phenomenon in children. The aim of this scoping review was to gather and summarize all evidence on ARC in pediatric patients to examine its breadth and depth including prevalence, risk factors, and pharmacokinetic alterations and identify any gaps for further areas of inquiry. PubMed, Embase, and Web of Science were searched for titles, abstracts, or keywords that focused on ARC. Non-English studies, reviews, and nonhuman studies were excluded. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. Data were extracted on article type, study details, patient population, ARC definition and prevalence, methods of renal function assessment, and study results. A total of 215 citations were found with 25 citations meeting the criteria for inclusion in pediatrics (2102 total patients); the majority of studies (84%) focused on pharmacokinetics (PK) of antimicrobial agents. The median/mean age range was 1.25-12 years. There were a total of 10 different definitions of ARC. The prevalence of ARC ranged from 7.8% to 78%. The most common method for documenting creatinine clearance (CrCl) was the modified Schwartz equation (64%). Only 20% of studies reported risk factors for ARC including low serum creatinine, increasing age, febrile neutropenia, male, septic shock, and treatment with antibiotics. Glycopeptide antimicrobials were the most evaluated class (42.9%) among the 21 antimicrobial drug studies. All studies reported increased drug clearance and/or poor probability of achieving target concentrations of the agents studied. ARC showed variable prevalence in pediatric patients likely due to the lack of a standard definition and many studies not considering age-related changes in CrCl with pediatric intensive care unit (PICU) patients. ARC was shown to impact PK of antibiotics commonly administered to pediatric patients, which may necessitate changes in standard dosing regimens.
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Affiliation(s)
- Denise H Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | | | - Nicholas R Nelson
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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29
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Hartman SJF, Zwiers AJM, van de Water NEC, van Rosmalen J, Struck J, Schulte J, Hartmann O, Pickkers P, Beunders R, Tibboel D, Schreuder MF, de Wildt SN. Proenkephalin as a new biomarker for pediatric acute kidney injury - reference values and performance in children under one year of age. Clin Chem Lab Med 2021; 58:1911-1919. [PMID: 32598298 DOI: 10.1515/cclm-2020-0381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022]
Abstract
Objectives Acute kidney injury (AKI) is common in critically ill children, but current biomarkers are suboptimal. Proenkephalin A 119-159 (PENK) is a promising new biomarker for AKI in adults, but pediatric data is lacking. We determined PENK reference intervals for healthy children, crucial for clinical implementation, and explored concentrations in critically ill infants aged under 1 year. Methods Observational cohort study in healthy infants and critically ill children aged 0-1 years. Reference values were determined using generalized additive models. Plasma PENK concentrations between healthy children and critically ill children with and without AKI, were compared using linear mixed modelling. The performance of PENK as AKI biomarker was compared to cystatin C (CysC) and β-trace protein (BTP) using receiver-operating-characteristic (ROC) analysis. Results PENK concentrations in 100 healthy infants were stable during the first year of life (median 517.3 pmol/L). Median PENK concentrations in 91 critically ill children, were significantly higher in those with AKI (n=40) (KDIGO Stage 1 507.9 pmol/L, Stage 2 704.0 pmol/L, Stage 3 930.5 pmol/L) than non-AKI patients (n=51, 432.2 pmol/L) (p < 0.001). PENK appeared to relate better to AKI diagnosis than CysC and BTP (AUROC PENK 0.858, CysC 0.770 and BTP 0.711) in the first 24 h after recruitment. Conclusions PENK reference values are much higher in young infants than adults, but clearly discriminate between children with and without AKI, with comparable or better performance than CysC and BTP. Our results illustrate the importance of establishing age-normalized reference values and indicate PENK as a promising pediatric AKI biomarker.
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Affiliation(s)
- Stan J F Hartman
- Department of Pharmacology and Toxicology, Radboudumc, Radboud Institute of Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Alexandra J M Zwiers
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nadies E C van de Water
- Department of Pharmacology and Toxicology, Radboudumc, Radboud Institute of Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | | - Peter Pickkers
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Remi Beunders
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatrics, Division of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboudumc, Radboud Institute of Health Sciences, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
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30
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Zhou R, Fang Y, Wang C, Zhou S. Knowledge, attitudes, and practices related to augmented renal clearance among pediatricians in China: A cross-sectional study. Medicine (Baltimore) 2021; 100:e26889. [PMID: 34397910 PMCID: PMC8360415 DOI: 10.1097/md.0000000000026889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/20/2021] [Indexed: 01/04/2023] Open
Abstract
Our purpose was to assess pediatricians' knowledge of augmented renal clearance (ARC).We conducted cross-sectional analyses of 500 pediatricians from 16 tertiary hospitals in Anhui Province, China. Pediatricians provided demographic information and were asked questions about their knowledge of ARC, including risk factors, evaluation tools, and the impact on patient prognosis, with a focus on the attitude and practice of pediatricians related to adjusting vancomycin regimens when ARC occurs.A total of 491 valid questionnaires were finally included, only 276 pediatricians stated that they "know about ARC." Compared with the "do not know about ARC" group, the "know about ARC" group was younger (43.7 ± 8.0 vs 48.0 ± 7.9, P < .001), and their main source of ARC knowledge was from social networking platforms. A total of 193 (70%) chose at least 4 of the following factors as risk factors for children with ARC: severe trauma, sepsis, burns, major surgery, lower disease severity, and hematological malignancies. A total of 110 (40%) and 105 (38%) pediatricians chose the Schwartz formula and cystatin C, respectively, as the indicators to evaluate the renal function of ARC children. Concerning the estimated glomerular filtration rate threshold to identify ARC children, 201 (73%) pediatricians chose 130 mL/min/1.73 m2, while 55 (20%) chose "age-dependent ARC thresholds." Overall, 220 (80%) respondents indicated that ARC would impact the treatment effect of vancomycin, but 149/220 (68%) were willing to adjust the vancomycin regimen; only 22/149 (8%) considered that the dose should be increased, but no one knew how to increase. Regarding the prognosis of ARC children, all respondents chose "unclear."ARC is relatively common in critically ill children, but pediatricians do not know much about it, as most of the current knowledge is based on adult studies. Furthermore, ARC is often confused with acute kidney injury, which would lead to very serious treatment errors. Therefore, more pediatric studies about ARC are needed, and ARC should be written into official pediatric guidelines as soon as possible to provide reference for pediatricians.
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Affiliation(s)
- Ran Zhou
- Department of Pharmacy, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Yuting Fang
- Department of Pharmacy, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Chunyan Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
| | - Shusheng Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui Province, China
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31
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Tu Q, Cotta M, Raman S, Graham N, Schlapbach L, Roberts JA. Individualized precision dosing approaches to optimize antimicrobial therapy in pediatric populations. Expert Rev Clin Pharmacol 2021; 14:1383-1399. [PMID: 34313180 DOI: 10.1080/17512433.2021.1961578] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction:Severe infections continue to impose a major burden on critically ill children and mortality rates remain stagnant. Outcomes rely on accurate and timely delivery of antimicrobials achieving target concentrations in infected tissue. Yet, developmental aspects, disease-related variables, and host factors may severely alter antimicrobial pharmacokinetics in pediatrics. The emergence of antimicrobial resistance increases the need for improved treatment approaches.Areas covered:This narrative review explores why optimization of antimicrobial therapy in neonates, infants, children, and adolescents is crucial and summarizes the possible dosing approaches to achieve antimicrobial individualization. Finally, we outline a roadmap toward scientific evidence informing the development and implementation of precision antimicrobial dosing in critically ill children.The literature search was conducted on PubMed using the following keywords: neonate, infant, child, adolescent, pediatrics, antimicrobial, pharmacokinetic, pharmacodynamic target, Bayes dosing software, optimizing, individualizing, personalizing, precision dosing, drug monitoring, validation, attainment, and software implementation. Further articles were sought from the references of the above searched articles.Expert opinion:Recently, technological innovations have emerged that enabled the development of individualized antimicrobial dosing approaches in adults. More work is required in pediatrics to make individualized antimicrobial dosing approaches widely operationalized in this population.
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Affiliation(s)
- Quyen Tu
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Menino Cotta
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sainath Raman
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Centre for Children's Health Research (CCHR), The University of Queensland, Brisbane, QLD, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Luregn Schlapbach
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, The University Children's Hospital Zurich, Switzerland
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Population pharmacokinetics and dosing optimization of vancomycin in infants, children and adolescents with augmented renal clearance. Antimicrob Agents Chemother 2021; 65:e0089721. [PMID: 34339268 DOI: 10.1128/aac.00897-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Augmented renal clearance (ARC) can cause underexposure to vancomycin, thereby increasing the risk of treatment failure. Our objective was to evaluate population pharmacokinetics and optimize the dosing regimen of vancomycin in the pediatric population with ARC. Sparse pharmacokinetic sampling and therapeutic drug monitoring (TDM) data were collected from pediatric patients with ARC treated with vancomycin. A pharmacokinetic model was developed using NONMEM 7.2. The dosing regimen was optimized using Monte Carlo dose simulations. A total of 242 vancomycin serum concentrations from 113 patients (age range 0.4 to 14.9 years, 49 females and 64 males) were available. Mean vancomycin dose was 58.8 mg/kg/day (13.6 mg/kg/dose), and mean vancomycin serum trough concentration was 6.5 mg/L. A one-compartment pharmacokinetic model with first order elimination was developed. Body weight and age were the most significant and positive covariates for clearance and volume of distribution. To the pediatric population with ARC, the current recommended vancomycin dose of 60 mg/kg/day was associated with a high risk of underdosing. To reach the target AUC/MIC of 400-700 in these pediatric patients, the vancomycin dose should be increased to 75 mg/kg/day for infants and children between 1 month and 12 years of age, and 70 mg/kg/day for adolescents between 12 and 18 years of age. In conclusion, a one-compartment pharmacokinetic model with first-order elimination was established with body weight and age as significant covariates. An optimal dosing regimen was developed in pediatric patients with ARC aged 1 month -18 years.
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Hartman SJF, Upadhyay PJ, Hagedoorn NN, Mathôt RAA, Moll HA, van der Flier M, Schreuder MF, Brüggemann RJ, Knibbe CA, de Wildt SN. Current Ceftriaxone Dose Recommendations are Adequate for Most Critically Ill Children: Results of a Population Pharmacokinetic Modeling and Simulation Study. Clin Pharmacokinet 2021; 60:1361-1372. [PMID: 34036552 PMCID: PMC8505376 DOI: 10.1007/s40262-021-01035-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 12/01/2022]
Abstract
Background and Objective Ceftriaxone is a cornerstone antibiotic for critically ill children with severe infections. Despite its widespread use, information on the pharmacokinetics of ceftriaxone is lacking in this population. We aimed to determine ceftriaxone pharmacokinetics in critically ill children and to propose ceftriaxone dosing guidelines resulting in adequate target attainment using population pharmacokinetic modeling and simulation. Methods Critically ill children (aged 0–18 years) treated with intravenous ceftriaxone (100 mg/kg once daily, infused in 30 minutes) and a central or arterial line in place were eligible. Opportunistic blood sampling for total and unbound ceftriaxone concentrations was used. Population pharmacokinetic analysis was performed using non-linear mixed-effects modeling on NONMEM™ Version 7.4.3. Simulations were performed to select optimal doses using probability of target attainment for two pharmacokinetic targets of the minimum inhibitory concentration (MIC) reflecting the susceptibility of pathogens (f T > MIC 100% and fT > 4 × MIC 100%). Results Two hundred and five samples for total and 43 time-matched samples for unbound plasma ceftriaxone concentrations were collected from 45 patients, median age 2.5 (range 0.1–16.7) years. A two-compartment model with bodyweight as the co-variate for volume of distribution and clearance, and creatinine-based estimated glomerular filtration rate as an additional covariate for clearance, best described ceftriaxone pharmacokinetics. For a typical patient (2.5 years, 14 kg) with an estimated glomerular filtration rate of 80 mL/min/1.73 m2, the current 100-mg/kg once-daily dose results in a probability of target attainment of 96.8% and 60.8% for a MIC of 0.5 mg/L and 4 × MIC (2 mg/L), respectively, when using fT > MIC 100% as a target. For a 50-mg/kg twice-daily regimen, the probability of target attainment was 99.9% and 93.4%, respectively. Conclusions The current dosing regimen of ceftriaxone provides adequate exposure for susceptible pathogens in most critically ill children. In patients with an estimated glomerular filtration rate of > 80 mL/min/1.73 m2 or in areas with a high prevalence of less-susceptible pathogens (MIC ≥ 0.5 mg/L), a twice-daily dosing regimen of 50 mg/kg can be considered to improve target attainment. Clinical Trial Registration POPSICLE study (ClinicalTrials.gov, NCT03248349, registered 14 August, 2017), PERFORM study (ClinicalTrials.gov, NCT03502993, registered 19 April, 2018). Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01035-9.
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Affiliation(s)
- Stan J F Hartman
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Parth J Upadhyay
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Nienke N Hagedoorn
- Division of General Pediatrics, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henriëtte A Moll
- Division of General Pediatrics, Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Michiel van der Flier
- Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands.,Section Pediatric Infectious Diseases, Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud Institute of Molecular Life Sciences, Amalia Children's Hospital, Radboudumc, Nijmegen, The Netherlands
| | - Roger J Brüggemann
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboudumc, Nijmegen, The Netherlands
| | - Catherijne A Knibbe
- Division of Systems Biomedicine and Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands.,Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands. .,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Intensive Care Medicine, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, The Netherlands.
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Hartman SJF, Brüggemann RJ, Orriëns L, Dia N, Schreuder MF, de Wildt SN. Pharmacokinetics and Target Attainment of Antibiotics in Critically Ill Children: A Systematic Review of Current Literature. Clin Pharmacokinet 2021; 59:173-205. [PMID: 31432468 PMCID: PMC7007426 DOI: 10.1007/s40262-019-00813-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pharmacokinetics (PK) are severely altered in critically ill patients due to changes in volume of distribution (Vd) and/or drug clearance (Cl). This affects the target attainment of antibiotics in critically ill children. We aimed to identify gaps in current knowledge and to compare published PK parameters and target attainment of antibiotics in critically ill children to healthy children and critically ill adults. METHODS Systematic literature search in PubMed, EMBASE and Web of Science. Articles were labelled as relevant when they included information on PK of antibiotics in critically ill, non-neonatal, pediatric patients. Extracted PK-parameters included Vd, Cl, (trough) concentrations, AUC, probability of target attainment, and elimination half-life. RESULTS 50 relevant articles were identified. Studies focusing on vancomycin were most prevalent (17/50). Other studies included data on penicillins, cephalosporins, carbapenems and aminoglycosides, but data on ceftriaxone, ceftazidime, penicillin and metronidazole could not be found. Critically ill children generally show a higher Cl and larger Vd than healthy children and critically ill adults. Reduced target-attainment was described in critically ill children for multiple antibiotics, including amoxicillin, piperacillin, cefotaxime, vancomycin, gentamicin, teicoplanin, amikacin and daptomycin. 38/50 articles included information on both Vd and Cl, but a dosing advice was given in only 22 articles. CONCLUSION The majority of studies focus on agents where TDM is applied, while other antibiotics lack data altogether. The larger Vd and higher Cl in critically ill children might warrant a higher dose or extended infusions of antibiotics in this patient population to increase target-attainment. Studies frequently fail to provide a dosing advice for this patient population, even if the necessary information is available. Our study shows gaps in current knowledge and encourages future researchers to provide dosing advice for special populations whenever possible.
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Affiliation(s)
- Stan J F Hartman
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
| | | | - Lynn Orriëns
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Nada Dia
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Michiel F Schreuder
- Division of Pediatric Nephrology, Department of Pediatrics, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology-Toxicology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.,Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands.,Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Population Pharmacokinetics and Outcomes of Critically Ill Pediatric Patients Treated with Intravenous Colistin at Higher Than Recommended Doses. Antimicrob Agents Chemother 2021; 65:AAC.00002-21. [PMID: 33782000 PMCID: PMC8316147 DOI: 10.1128/aac.00002-21] [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: 01/01/2021] [Accepted: 03/18/2021] [Indexed: 12/18/2022] Open
Abstract
Limited pharmacokinetic (PK) data suggest that currently recommended pediatric dosages of colistimethate sodium (CMS) by the Food and Drug Administration and European Medicines Agency may lead to suboptimal exposure, resulting in plasma colistin concentrations that are frequently <2 mg/liter. We conducted a population PK study in 17 critically ill patients 3 months to 13.75 years (median, 3.3 years) old who received CMS for infections caused by carbapenem-resistant Gram-negative bacteria. CMS was dosed at 200,000 IU/kg/day (6.6 mg colistin base activity [CBA]/kg/day; 6 patients), 300,000 IU/kg/day (9.9 mg CBA/kg/day; 10 patients), and 350,000 IU/kg/day (11.6 mg CBA/kg/day; 1 patient). Plasma colistin concentrations were determined using ultraperformance liquid chromatography combined with electrospray ionization-tandem mass spectrometry. Colistin PK was described by a one-compartment disposition model, including creatinine clearance, body weight, and the presence or absence of systemic inflammatory response syndrome (SIRS) as covariates (P < 0.05 for each). The average colistin plasma steady-state concentration (Css,avg) ranged from 1.11 to 8.47 mg/liter (median, 2.92 mg/liter). Ten patients had Css,avg of ≥2 mg/liter. The presence of SIRS was associated with decreased apparent clearance of colistin (47.8% of that without SIRS). The relationship between the number of milligrams of CBA per day needed to achieve each 1 mg/liter of plasma colistin Css,avg and creatinine clearance (in milliliters per minute) was described by linear regression with different slopes for patients with and without SIRS. Nephrotoxicity, probably unrelated to colistin, was observed in one patient. In conclusion, administration of CMS at the above doses improved exposure and was well tolerated. Apparent clearance of colistin was influenced by creatinine clearance and the presence or absence of SIRS.
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Avedissian SN, Rhodes NJ, Kim Y, Bradley J, Valdez JL, Le J. Augmented renal clearance of aminoglycosides using population-based pharmacokinetic modelling with Bayesian estimation in the paediatric ICU. J Antimicrob Chemother 2021; 75:162-169. [PMID: 31648297 DOI: 10.1093/jac/dkz408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/21/2019] [Accepted: 08/24/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate augmented renal clearance (ARC) using aminoglycoside clearance (CLAMINO24h) derived from pharmacokinetic (PK) modelling. METHODS A retrospective study at two paediatric hospitals of patients who received tobramycin or gentamicin from 1999 to 2016 was conducted. Compartmental PK models were constructed using the Pmetrics package, and Bayesian posteriors were used to estimate CLAMINO24h. ARC was defined as a CLAMINO24h of ≥130 mL/min/1.73 m2. Risk factors for ARC were identified using multivariate logistic regression. RESULTS The final population model was fitted to 275 aminoglycoside serum concentrations. Overall clearance (L/h) was=CL0×(TBW/70)0.75×AGEH/(TMH + AGEH) + CL1 (0.5/SCr), where TBW is total body weight, H is the Hill coefficient, TM is a maturation term and SCr is serum creatinine. Median CLAMINO24h in those with versus without ARC was 157.36 and 93.42 mL/min/1.73 m2, respectively (P<0.001). ARC was identified in 19.5% of 118 patients. For patients with ARC, median baseline SCr was lower than for those without ARC (0.38 versus 0.41 mg/dL, P=0.073). Risk factors for ARC included sepsis [adjusted OR (aOR) 3.77, 95% CI 1.01-14.07, P=0.048], increasing age (aOR 1.11, 95% CI 1-1.23, P=0.04) and low log-transformed SCr (aOR 0.16, 95% CI 0.05-0.52, P=0.002). Median 24 h AUC (AUC24h) was significantly lower in patients with ARC at 45.27 versus 56.95 mg·h/L, P<0.01. CONCLUSIONS ARC was observed in one of every five patients. Sepsis, increasing age and low SCr were associated with ARC. Increased clearance was associated with an attenuation of AUC24h in this population. Future studies are needed to define optimal dosing in paediatric patients with ARC.
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Affiliation(s)
- Sean N Avedissian
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA.,Midwestern University Chicago College of Pharmacy Center of Pharmacometric Excellence, Midwestern University, Downers Grove, IL, USA.,Antiviral Pharmacology Laboratory, University of Nebraska Medical Center (UNMC) Center for Drug Discovery, UNMC, Omaha, NE, USA.,University of Nebraska Medical Center, College of Pharmacy, Omaha, NE, USA
| | - Nathaniel J Rhodes
- Midwestern University Chicago College of Pharmacy, Downers Grove, IL, USA.,Midwestern University Chicago College of Pharmacy Center of Pharmacometric Excellence, Midwestern University, Downers Grove, IL, USA
| | - Yuna Kim
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA
| | - John Bradley
- Division of Infectious Diseases, University of California San Diego School of Medicine and Rady Children's Hospital San Diego, CA, USA
| | - Joshua L Valdez
- Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - Jennifer Le
- University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, San Diego, CA, USA.,Miller Children's and Women's Hospital of Long Beach, Long Beach, CA, USA
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Population Pharmacokinetics of Intravenous Ganciclovir and Oral Valganciclovir in a Pediatric Population To Optimize Dosing Regimens. Antimicrob Agents Chemother 2021; 65:AAC.02254-20. [PMID: 33318012 DOI: 10.1128/aac.02254-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/11/2020] [Indexed: 12/11/2022] Open
Abstract
Ganciclovir is indicated for curative or preventive treatment of cytomegalovirus (CMV) infections. This study aimed to characterize ganciclovir pharmacokinetics, following intravenous ganciclovir and oral valganciclovir administration, to optimize dosing schemes. All children aged <18 years receiving ganciclovir or valganciclovir were included in this study. Pharmacokinetics were described using nonlinear mixed-effect modeling. Monte Carlo simulations were used to optimize the dosing regimen to maintain the area under the concentration-time curve (AUC) in the preventive or therapeutic target. Among the 105 children (374 concentration-time observations) included, 78 received intravenous (i.v.) ganciclovir, 19 received oral valganciclovir, and 6 received both drugs. A two-compartment model with first-order absorption for valganciclovir and first-order elimination best described the data. An allometric model was used to describe the bodyweight (BW) effect. Estimated glomerular filtration rate (eGFR) and medical status of critically ill children were significantly associated with ganciclovir elimination. Recommended doses were adapted for prophylactic treatment. To obtain a therapeutic exposure, doses should be increased to 40 mg/kg of body weight/day oral or 15 to 20 mg/kg/day i.v. in children with normal eGFR and to 56 mg/kg/day oral or 20 to 25 mg/kg/day i.v. in children with augmented eGFR. These doses should be prospectively confirmed, and therapeutic drug monitoring could be used to refine them individually. (This study has been registered at ClinicalTrials.gov under identifier NCT02539407.).
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Fratoni AJ, Nicolau DP, Kuti JL. A guide to therapeutic drug monitoring of β-lactam antibiotics. Pharmacotherapy 2021; 41:220-233. [PMID: 33480024 DOI: 10.1002/phar.2505] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/13/2022]
Abstract
Therapeutic drug monitoring (TDM) opens the door to personalized medicine, yet it is infrequently applied to β-lactam antibiotics, one of the most commonly prescribed drug classes in the hospital setting. As we continue to understand more about β-lactam pharmacodynamics (PD) and wide inter- and intra-patient variability in pharmacokinetics (PK), the utility of TDM has become increasingly apparent. For β-lactams, the time that free concentrations remain above the minimum inhibitory concentration (MIC) as a function of the dosing interval (%fT>MIC) has been shown to best predict antibacterial effect. Many studies have shown that β-lactam %fT>MIC exposures are often suboptimal across a wide variety of disease states and clinical settings. A limitation to implementing this practice is the general lack of understanding on how to best operationalize this intervention and interpret the results. The instrumentation and expertise needed to quantify β-lactams for TDM is rarely available locally, but certain laboratories advertise these services and perform them regularly. Familiarity with the modalities and nuances of antimicrobial susceptibility testing is crucial to establishing β-lactam concentration targets that meet the relevant exposure thresholds. Evaluation of these concentrations is best accomplished using population PK software and Bayesian modeling, for which a multitude of programs are available. While TDM of β-lactams has shown an ability to increase the rate of target attainment, there is currently limited evidence to suggest that it leads to improved clinical outcomes. Although consensus guidelines for β-lactam TDM do not exist in the United States, guidance would help to promote this important practice and better standardize the approach across institutions. Herein, we discuss the basis for β-lactam TDM, review supporting evidence, and provide guidance for implementation in specific patient populations.
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Affiliation(s)
- Andrew J Fratoni
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - David P Nicolau
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Joseph L Kuti
- Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
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Landersdorfer CB, Nation RL. Key Challenges in Providing Effective Antibiotic Therapy for Critically Ill Patients with Bacterial Sepsis and Septic Shock. Clin Pharmacol Ther 2021; 109:892-904. [PMID: 33570163 DOI: 10.1002/cpt.2203] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
Early initiation of effective antibiotic therapy is vitally important for saving the lives of critically ill patients with sepsis or septic shock. The susceptibility of the infecting pathogen and the ability of the selected dosage regimen to safely achieve the required antibiotic exposure need to be carefully considered to achieve a high probability of a successful outcome. Critically ill patients commonly experience substantial pathophysiological changes that impact the functions of various organs, including the kidneys. Many antibiotics are predominantly renally eliminated and thus renal function is a major determinant of the regimen needed to achieve the required antibiotic exposure. However, currently, there is a paucity of guidelines to inform antibiotic dosing in critically ill patients, including those with sepsis or septic shock. This paper briefly reviews methods that are commonly used in critically ill patients to provide a measure of renal function, and approaches that describe the relationship between the exposure to an antibiotic and its antibacterial effects. Two common conditions that very substantially complicate the use of antibiotics in critically ill patients with sepsis, unstable renal function, and augmented renal clearance, are considered in detail and their potential therapeutic implications are explored. Suggestions are provided on how treatment of bacterial infections in critically ill patients with sepsis might be improved. Of high potential are model-informed approaches that aim to individualize initial treatment regimens based on patient and bacterial characteristics, with refinement of regimens during treatment in response to monitoring antibiotic concentrations, responsive measures of renal function, and other important clinical data.
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Affiliation(s)
- Cornelia B Landersdorfer
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Roger L Nation
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Population Pharmacokinetics and Pharmacodynamics of Meropenem in Critically Ill Pediatric Patients. Antimicrob Agents Chemother 2021; 65:AAC.01909-20. [PMID: 33199385 DOI: 10.1128/aac.01909-20] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 12/27/2022] Open
Abstract
This study investigates the optimal meropenem (MEM) dosing regimen for critically ill pediatric patients, for which there is a lack of pharmacokinetic (PK) studies. We conducted a retrospective single-center PK and pharmacodynamic (PD) analysis of 34 pediatric intensive care unit patients who received MEM. Individual PK parameters were determined by a two-compartment analysis. The median (range) age and body weight were 1.4 (0.03 to 14.6) years and 8.9 (2.7 to 40.9) kg, respectively, and eight (23.5%) patients received continuous renal replacement therapy (CRRT), three of whom received extracorporeal membrane oxygenation. Renal function, the systemic inflammatory response syndrome (SIRS) score for the clearance (CL), and the use of CRRT for the central volume of distribution (V c) were identified as significant covariates. The mean CL, V c, and peripheral volume of distribution (V p) were 0.45 liters/kg/h, 0.49 liters/kg, and 0.34 liters/kg, respectively. The mean population CL of MEM increased by 35% in patients with SIRS and V c increased by 66% in patients on CRRT in the final model. Dosing simulations suggested that the standard dosing regimen provided insufficient PD exposures of a 100% free time above the MIC, and higher doses (40 to 80 mg/kg of body weight/dose every 8 h) with a prolonged 3-h infusion were required to ensure the appropriate PD exposures for patients with SIRS. Our PK model indicated that critically ill pediatric patients are at risk of subtherapeutic exposure under the standard dosing regimen of MEM. A larger, prospective investigation confirming the safety and efficacy of higher concentrations and prolonged infusion of MEM is necessary.
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Willems J, Hermans E, Schelstraete P, Depuydt P, De Cock P. Optimizing the Use of Antibiotic Agents in the Pediatric Intensive Care Unit: A Narrative Review. Paediatr Drugs 2021; 23:39-53. [PMID: 33174101 PMCID: PMC7654352 DOI: 10.1007/s40272-020-00426-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 02/08/2023]
Abstract
Antibiotics are one of the most prescribed drug classes in the pediatric intensive care unit, yet the incidence of inappropriate antibiotic prescribing remains high in critically ill children. Optimizing the use of antibiotics in this population is imperative to guarantee adequate treatment, avoid toxicity and the occurrence of antibiotic resistance, both on a patient level and on a population level. Antibiotic stewardship encompasses all initiatives to promote responsible antibiotic usage and the PICU represents a major target environment for antibiotic stewardship programs. This narrative review provides a summary of the available knowledge on the optimal selection, duration, dosage, and route of administration of antibiotic treatment in critically ill children. Overall, more scientific evidence on how to optimize antibiotic treatment is warranted in this population. We also give our personal expert opinion on research priorities.
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Affiliation(s)
- Jef Willems
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium
| | - Eline Hermans
- Department of Pediatrics, Ghent University Hospital, Gent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium
| | - Petra Schelstraete
- Department of Pediatric Pulmonology, Ghent University Hospital, Gent, Belgium
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, Gent, Belgium
| | - Pieter De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium.
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium.
- Department of Pharmacy, Ghent University Hospital, Gent, Belgium.
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André P, Diezi L, Dao K, Crisinel PA, Rothuizen LE, Chtioui H, Decosterd LA, Diezi M, Asner S, Buclin T. Ensuring Sufficient Trough Plasma Concentrations for Broad-Spectrum Beta-Lactam Antibiotics in Children With Malignancies: Beware of Augmented Renal Clearance! Front Pediatr 2021; 9:768438. [PMID: 35083184 PMCID: PMC8785252 DOI: 10.3389/fped.2021.768438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction: Broad-spectrum beta-lactams are commonly prescribed for empirical or selective treatment of bacterial infections in children with malignancies. In the immunocompromised, appropriate concentration exposure is crucial to ensure antimicrobial efficacy. Augmented renal clearance (ARC) is increasingly recognized in this population, and raises concern for unmet concentration targets. We conducted a retrospective evaluation of meropenem and piperacillin exposure in our hospital's pediatric hematology-oncology patients. Materials and Methods: We compared trough levels of meropenem and piperacillin in a cohort of unselected pediatric hematology-oncology patients stratified based on their estimated renal function as decreased, normal or with ARC, and on their neutrophil count. Results: Thirty-two children provided a total of 51 meropenem and 76 piperacillin samples. On standard intermittent intravenous regimen, 67% of all trough plasma concentrations were below targeted concentrations. In neutropenic children with bacterial infection, all meropenem and 60% of piperacillin levels were below target. Nearly two-thirds of total samples came from children with ARC. In these patients, antimicrobial exposure was insufficient in 85% of cases (compared to 36% in the decreased or normal renal function groups), despite a dosage sometimes exceeding the maximum recommended daily dose. Under continuous infusion of piperacillin, only 8% of plasma levels were insufficient. Discussion: Intermittent administration of meropenem and piperacillin often fails to ensure sufficient concentration exposure in children treated for malignancies, even at maximal recommended daily dosage. This can in part be attributed to ARC. We recommend thorough assessment of renal function, resolute dosage adjustment, continuous infusion whenever possible and systematic therapeutic drug monitoring.
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Affiliation(s)
- Pascal André
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Léonore Diezi
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Kim Dao
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Pierre Alex Crisinel
- Pediatric Infectious Diseases and Vaccinology Unit, Service of Pediatrics, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Laura E Rothuizen
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Haithem Chtioui
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Laurent Arthur Decosterd
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Manuel Diezi
- Pediatric Hemato-Oncology Unit, Service of Pediatrics, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Sandra Asner
- Pediatric Infectious Diseases and Vaccinology Unit, Service of Pediatrics, University Hospital Center, University of Lausanne, Lausanne, Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology, University Hospital Center, University of Lausanne, Lausanne, Switzerland
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Population Pharmacokinetics of Intravenous and Oral Acyclovir and Oral Valacyclovir in Pediatric Population To Optimize Dosing Regimens. Antimicrob Agents Chemother 2020; 64:AAC.01426-20. [PMID: 32988829 DOI: 10.1128/aac.01426-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/19/2020] [Indexed: 02/04/2023] Open
Abstract
Acyclovir is an antiviral currently used for the prevention and treatment of herpes simplex virus (HSV) and varicella-zoster virus (VZV) infections. This study aimed to characterize the pharmacokinetics (PK) of acyclovir and its oral prodrug valacyclovir to optimize dosing in children. Children receiving acyclovir or valacyclovir were included in this study. PK were described using nonlinear mixed-effect modeling. Dosing simulations were used to obtain trough concentrations above a 50% inhibitory concentration for HSV or VZV (0.56 mg/liter and 1.125 mg/liter, respectively) and maximal peak concentrations below 25 mg/liter. A total of 79 children (212 concentration-time observations) were included: 50 were taking intravenous (i.v.) acyclovir, 22 were taking oral acyclovir, and 7 were taking both i.v. and oral acyclovir, 57 for preventive and 22 for curative purposes. A one-compartment model with first-order elimination best described the data. An allometric model was used to describe body weight effect, and the estimated glomerular filtration rate (eGFR) was significantly associated with acyclovir elimination. To obtain target maximal and trough concentrations, the more suitable initial acyclovir i.v. dose was 10 mg/kg of body weight/6 h for children with normal renal function (eGFR ≤ 250 ml/min/1.73 m2) and 15 to 20 mg/kg/6 h for children with augmented renal clearance (ARC) (eGFR > 250 ml/min/1.73 m2). The 20-mg/kg/8 h dose for oral acyclovir and valacyclovir produced effective concentrations in more than 75% of children; however, a 15-mg/kg/6 h dose, if possible, is preferred. These doses should be prospectively confirmed, and therapeutic drug monitoring could be used to refine them individually. (This study has been registered at ClinicalTrials.gov under identifier NCT02539407.).
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Aulin LBS, De Paepe P, Dhont E, de Jaeger A, Vande Walle J, Vandenberghe W, McWhinney BC, Ungerer JPJ, van Hasselt JGC, De Cock PAJG. Population Pharmacokinetics of Unbound and Total Teicoplanin in Critically Ill Pediatric Patients. Clin Pharmacokinet 2020; 60:353-363. [PMID: 33030704 DOI: 10.1007/s40262-020-00945-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Teicoplanin is a highly protein-bound antibiotic, increasingly used to treat serious Gram-positive infections in critically ill children. Maturational and pathophysiological intensive care unit-related changes often lead to altered pharmacokinetics. In this study, the objectives were to develop a pediatric population-pharmacokinetic model of unbound and total teicoplanin concentrations, to investigate the impact of plasma albumin levels and renal function on teicoplanin pharmacokinetics, and to evaluate the efficacy of the current weight-based dosing regimen. METHODS An observational pharmacokinetic study was performed and blood samples were collected for quantification of unbound and total concentrations of teicoplanin after the first dose and in assumed steady-state conditions. A population-pharmacokinetic analysis was conducted using a standard sequential approach and Monte Carlo simulations were performed for a probability of target attainment analysis using previously published pharmacokinetic-pharmacodynamic targets. RESULTS A two-compartment model with allometric scaling of pharmacokinetic parameters and non-linear plasma protein binding best described the data. Neither the inclusion of albumin nor the renal function significantly improved the model and no other covariates were supported for inclusion in the final model. The probability of target attainment analysis showed that the standard dosing regimen does not satisfactory attain the majority of the proposed targets. CONCLUSIONS We successfully characterized the pharmacokinetics of unbound and total teicoplanin in critically ill pediatric patients. The highly variable unbound fraction of teicoplanin could not be predicted using albumin levels, which may support the use of therapeutic drug monitoring of unbound concentrations. Poor target attainment was shown for the most commonly used dosing regimen, regardless of the pharmacokinetic-pharmacodynamic target evaluated.
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Affiliation(s)
- L B S Aulin
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - P De Paepe
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium
| | - E Dhont
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - A de Jaeger
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - J Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - W Vandenberghe
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - B C McWhinney
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - J P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia.,School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - J G C van Hasselt
- Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - P A J G De Cock
- Heymans Institute of Pharmacology, Ghent University, Ghent, Belgium. .,Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium. .,Department of Pharmacy, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
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Augmented Renal Clearance and How to Augment Antibiotic Dosing. Antibiotics (Basel) 2020; 9:antibiotics9070393. [PMID: 32659898 PMCID: PMC7399877 DOI: 10.3390/antibiotics9070393] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 01/02/2023] Open
Abstract
Augmented renal clearance (ARC) refers to the state of heightened renal filtration commonly observed in the critically ill. Its prevalence in this patient population is a consequence of the body’s natural response to serious disease, as well as the administration of fluids and pharmacologic therapies necessary to maintain sufficient blood pressure. ARC is objectively defined as a creatinine clearance of more than 130 mL/min/1.73 m2 and is thus a crucial condition to consider when administering antibiotics, many of which are cleared renally. Using conventional dosing regimens risks the possibility of subtherapeutic concentrations or clinical failure. Over the past decade, research has been conducted in patients with ARC who received a number of antibacterials frequently used in the critically ill, such as piperacillin-tazobactam or vancomycin. Strategies to contend with this condition have also been explored, though further investigations remain necessary.
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46
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Chosidow A, Benaboud S, Beranger A, Zheng Y, Moulin F, Dupic L, Renolleau S, Treluyer JM, Oualha M. Are β-lactam concentrations adequate in severe sepsis and septic shock in children? Therapie 2020; 75:633-640. [PMID: 32593420 DOI: 10.1016/j.therap.2020.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/18/2019] [Accepted: 04/02/2020] [Indexed: 01/16/2023]
Abstract
AIM OF THE STUDY Early administration of appropriate antibiotic therapy with adequate concentration is the cornerstone of the severe sepsis and septic shock's treatment. We aim to describe the plasma concentration of the most used β-lactams in critically ill children, to describe the rate of patients with suboptimal exposure, and associated clinical and biological factors. METHODS From January 2016 to May 2017, children less than 18 years old with severe sepsis or septic shock were included. Samples were collected in pediatric intensive care unit for children with severe sepsis or septic shock. β-lactam plasma concentrations were analysed using high performance liquid chromatography. RESULTS Among the 37 enrolled patients, 24 (64.9%) had insufficient concentration [cefotaxime 7/14 (43%); piperacillin-tazobactam, 10/13 (77%); amoxicillin 6/7 (86%); meropenem 3/6 (50%), cefazolin 1/4 (25%), imipenem 0/2 (0%); ceftazidime 0/1 (0%)]. Insufficient concentrations were associated with early measurements [<72hours from the sepsis' onset (P=0.035) and an increased creatinine clearance (P=0.01)]. CONCLUSION β-lactams current dosing in critically ill septic children could be suboptimal.
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Affiliation(s)
- Anais Chosidow
- Armand-Trousseau hospital, AP-HP, pediatric department, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France.
| | - Sihem Benaboud
- Pharmacology department, Cochin hospital, 75014 Paris, France
| | - Agathe Beranger
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Yi Zheng
- Pharmacology department, Cochin hospital, 75014 Paris, France
| | - Florence Moulin
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Laurent Dupic
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | | | - Jean-Marc Treluyer
- Pharmacology department, Cochin hospital, 75014 Paris, France; Pediatric intensive care unit, Necker hospital, 75015 Paris, France
| | - Mehdi Oualha
- Pediatric intensive care unit, Necker hospital, 75015 Paris, France
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Avedissian SN, Skochko SM, Le J, Hingtgen S, Harvey H, Capparelli EV, Richardson A, Momper J, Mak RH, Neely M, Bradley JS. Use of Simulation Strategies to Predict Subtherapeutic Meropenem Exposure Caused by Augmented Renal Clearance in Critically Ill Pediatric Patients With Sepsis. J Pediatr Pharmacol Ther 2020; 25:413-422. [PMID: 32641911 PMCID: PMC7337137 DOI: 10.5863/1551-6776-25.5.413] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The objectives of this study were to 1) define extent and potential clinical impact of increased or decreased renal elimination of meropenem in children with sepsis, based on analysis of renal function during the first 2 days of PICU stay; and 2) estimate the risk of subtherapeutic meropenem exposure attributable to increased renal clearance. METHODS This retrospective study evaluated patients with a diagnosis of sepsis, receiving meropenem from the PICU at Rady Children's Hospital San Diego from 2015-2017. Meropenem exposure was estimated by using FDA-approved doses (20 and 40 mg/kg/dose) on day 1 and day 2 of PICU stay, based on a population pharmacokinetic (PK) model. For this population with sepsis, we assessed time-above-minimum inhibitory concentration (T>MIC) for pathogen MICs. RESULTS Meropenem treatment was documented in 105 episodes of sepsis with a 48% rate of pathogen detection. By day 2, increased eGFR (>120 mL/min/1.73 m2) was documented in 49% of patients, with 17% meeting criteria for augmented renal clearance ([ARC] >160 mL/min/1.73 m2) and 10%, for decreased function. Simulations documented that 80% of PICU patients with ARC did not achieve therapeutic meropenem exposure for Pseudomonas aeruginosa with a MIC of 2, using standard doses to achieve a pharmacodynamic goal of 80% T>MIC. CONCLUSIONS Approximately 3 of every 20 children with sepsis exhibited ARC during the first 48 hours of PICU stay. Simulations documented an increased risk for subtherapeutic meropenem exposure, suggesting that higher meropenem doses may be required to achieve adequate antibiotic exposure early in the PICU course.
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Saffioti C, Mesini A, Barco S, Cangemi G, Bandettini R, Castagnola E. Piperacillin-tazobactam concentration target attainment in children with cancer. Pediatr Blood Cancer 2019; 66:e27882. [PMID: 31222911 DOI: 10.1002/pbc.27882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/08/2022]
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Raffaeli G, Pokorna P, Allegaert K, Mosca F, Cavallaro G, Wildschut ED, Tibboel D. Drug Disposition and Pharmacotherapy in Neonatal ECMO: From Fragmented Data to Integrated Knowledge. Front Pediatr 2019; 7:360. [PMID: 31552205 PMCID: PMC6733981 DOI: 10.3389/fped.2019.00360] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/16/2019] [Indexed: 12/27/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving support technology for potentially reversible neonatal cardiac and/or respiratory failure. As the survival and the overall outcome of patients rely on the treatment and reversal of the underlying disease, effective and preferentially evidence-based pharmacotherapy is crucial to target recovery. Currently limited data exist to support the clinicians in their every-day intensive care prescribing practice with the contemporary ECMO technology. Indeed, drug dosing to optimize pharmacotherapy during neonatal ECMO is a major challenge. The impact of the maturational changes of the organ function on both pharmacokinetics (PK) and pharmacodynamics (PD) has been widely established over the last decades. Next to the developmental pharmacology, additional non-maturational factors have been recognized as key-determinants of PK/PD variability. The dynamically changing state of critical illness during the ECMO course impairs the achievement of optimal drug exposure, as a result of single or multi-organ failure, capillary leak, altered protein binding, and sometimes a hyperdynamic state, with a variable effect on both the volume of distribution (Vd) and the clearance (Cl) of drugs. Extracorporeal membrane oxygenation introduces further PK/PD perturbation due to drug sequestration and hemodilution, thus increasing the Vd and clearance (sequestration). Drug disposition depends on the characteristics of the compounds (hydrophilic vs. lipophilic, protein binding), patients (age, comorbidities, surgery, co-medications, genetic variations), and circuits (roller vs. centrifugal-based systems; silicone vs. hollow-fiber oxygenators; renal replacement therapy). Based on the potential combination of the above-mentioned drug PK/PD determinants, an integrated approach in clinical drug prescription is pivotal to limit the risks of over- and under-dosing. The understanding of the dose-exposure-response relationship in critically-ill neonates on ECMO will enable the optimization of dosing strategies to ensure safety and efficacy for the individual patient. Next to in vitro and clinical PK data collection, physiologically-based pharmacokinetic modeling (PBPK) are emerging as alternative approaches to provide bedside dosing guidance. This article provides an overview of the available evidence in the field of neonatal pharmacology during ECMO. We will identify the main determinants of altered PK and PD, elaborate on evidence-based recommendations on pharmacotherapy and highlight areas for further research.
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Affiliation(s)
- Genny Raffaeli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Pavla Pokorna
- Department of Pediatrics—ICU, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University, Prague, Czechia
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Karel Allegaert
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy
| | - Enno D. Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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Risk Factors and Clinical Outcomes Associated With Augmented Renal Clearance in Trauma Patients. J Surg Res 2019; 244:477-483. [PMID: 31330291 DOI: 10.1016/j.jss.2019.06.087] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/21/2019] [Accepted: 06/20/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Augmented renal clearance (ARC; i.e., creatinine clearance [CLCr] ≥ 130 mL/min) has an incidence of 14%-80% in critically ill patients and has been associated with therapy failures for renally cleared drugs. However, the clinical implications of ARC are poorly defined. We hypothesize that modifiable risk factors that contribute to ARC can be identified in severely injured trauma patients and that these risk factors influence clinical outcome. METHODS In 207 trauma intensive care unit patients, 24-h CLCr was correlated with clinical estimates of glomerular filtration rate (by Cockroft-Gault, modification of diet in renal disease, or chronic kidney disease epidemiology), and clinical outcomes (infection, venous thromboembolism [VTE], length of stay, and mortality). RESULTS The population was 45 ± 20 y, 68% male, 77% blunt injury with injury severity score of 24 (17-30). Admission serum creatinine was 1.02 ± 0.35 mg/dL, CLCr was 154 ± 77 mL/min, VTE incidence was 15%, ARC incidence was 57%, and mortality was 11%. Clinical estimates of glomerular filtration rate by Cockroft-Gault, modification of diet in renal disease, chronic kidney disease epidemiology underestimated actual CLCr by 20%, 22%, or 15% (all P < 0.01). CLCr was higher in males and those who survived, and lower in those with hypertension, diabetes, positive cultures, receiving transfusions, or pressors (all P < 0.05). On multivariate analysis, male gender (odds ratio [OR] 2.9 [1.4-6.1]), age (OR 0.97 [0.95-0.99]), and packed red blood cells transfusion (OR 0.31 [0.15-0.66]) were the only independent predictors of ARC. CONCLUSIONS ARC occurs in more than half of all high-risk trauma intensive care unit patients and is underestimated by standard clinical equations. ARC was not associated with increased incidence of VTE or infection but rather is associated with younger healthier males and reduced mortality. ARC seems to be a beneficial compensatory response to trauma.
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