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Wong S, Selby PR, Reuter SE. Determination of a vancomycin nephrotoxicity threshold and assessment of target attainment in hematology patients. Pharmacol Res Perspect 2024; 12:e1231. [PMID: 38940223 PMCID: PMC11211924 DOI: 10.1002/prp2.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024] Open
Abstract
An area-under-the-curve (AUC24)-based approach is recommended to guide vancomycin therapeutic drug monitoring (TDM), yet trough concentrations are still commonly used despite associated risks. A definitive toxicity target is lacking, which is important for hematology patients who have a higher risk of nephrotoxicity. The aims were to (1) assess the impact of trough-based TDM on acute kidney injury (AKI) incidence, (2) establish a vancomycin nephrotoxicity threshold, and (3) evaluate the proportion of hematology patients achieving vancomycin therapeutic targets. Retrospective data was collected from 100 adult patients with a hematological malignancy or aplastic anemia who received vancomycin between April 2020 and January 2021. AKI occurrence was determined based on serum creatinine concentrations, and individual pharmacokinetic parameters were estimated using a Bayesian approach. Receiver operating characteristic (ROC) curve analysis was performed to assess the ability of pharmacokinetic indices to predict AKI occurrence. The proportion of patients who achieved target vancomycin exposure was evaluated based on an AUC24/MIC ≥400 and the determined toxicity threshold. The incidence of AKI was 37%. ROC curve analysis indicated a maximum AUC24 of 644 mg.h/L over the treatment period was an important predictor of AKI. By Day 4 of treatment, 29% of treatment courses had supratherapeutic vancomycin exposure, with only 62% of courses achieving AUC24 targets. The identified toxicity threshold supports an AUC24 target range of 400-650 mg.h/L, assuming an MIC of 1 mg/L, to optimize vancomycin efficacy and minimize toxicity. This study highlights high rates of AKI in this population and emphasizes the importance of transitioning from trough-based TDM to an AUC-based approach to improve clinical outcomes.
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Affiliation(s)
- Sherilyn Wong
- UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Philip R. Selby
- UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- School of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
- SA Pharmacy, Royal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Stephanie E. Reuter
- UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
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Tootooni MS, Barreto EF, Wutthisirisart P, Kashani KB, Pasupathy KS. Determining steady-state trough range in vancomycin drug dosing using machine learning. J Crit Care 2024; 82:154784. [PMID: 38503008 PMCID: PMC11139571 DOI: 10.1016/j.jcrc.2024.154784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Vancomycin is a renally eliminated, nephrotoxic, glycopeptide antibiotic with a narrow therapeutic window, widely used in intensive care units (ICU). We aimed to predict the risk of inappropriate vancomycin trough levels and appropriate dosing for each ICU patient. METHODS Observed vancomycin trough levels were categorized into sub-therapeutic, therapeutic, and supra-therapeutic levels to train and compare different classification models. We included adult ICU patients (≥ 18 years) with at least one vancomycin concentration measurement during hospitalization at Mayo Clinic, Rochester, MN, from January 2007 to December 2017. RESULT The final cohort consisted of 5337 vancomycin courses. The XGBoost models outperformed other machine learning models with the AUC-ROC of 0.85 and 0.83, specificity of 53% and 47%, and sensitivity of 94% and 94% for sub- and supra-therapeutic categories, respectively. Kinetic estimated glomerular filtration rate and other creatinine-based measurements, vancomycin regimen (dose and interval), comorbidities, body mass index, age, sex, and blood pressure were among the most important variables in the models. CONCLUSION We developed models to assess the risk of sub- and supra-therapeutic vancomycin trough levels to improve the accuracy of drug dosing in critically ill patients.
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Affiliation(s)
- M Samie Tootooni
- Department of Health Informatics and Data Science, Loyola University Chicago, Maywood, IL, United States of America.
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States of America
| | - Phichet Wutthisirisart
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States of America
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, United States of America.
| | - Kalyan S Pasupathy
- Department of Biomedical and Health Information Sciences, University of Illinois Chicago, Chicago, IL, United States of America.
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Blouin M, Métras MÉ, El Hassani M, Yaliniz A, Marsot A. Optimization of Vancomycin Initial Dosing Regimen in Neonates Using an Externally Evaluated Population Pharmacokinetic Model. Ther Drug Monit 2024:00007691-990000000-00235. [PMID: 38857472 DOI: 10.1097/ftd.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/27/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Vancomycin therapeutic monitoring guidelines were revised in March 2020, and a population pharmacokinetics-guided Bayesian approach to estimate the 24-hour area under the concentration-time curve to the minimum inhibitory concentration ratio has since been recommended instead of trough concentrations. To comply with these latest guidelines, we evaluated published population pharmacokinetic models of vancomycin using an external dataset of neonatal patients and selected the most predictive model to develop a new initial dosing regimen. METHODS The models were identified from the literature and tested using a retrospective dataset of Canadian neonates. Their predictive performance was assessed using prediction- and simulation-based diagnostics. Monte Carlo simulations were performed to develop the initial dosing regimen with the highest probability of therapeutic target attainment. RESULTS A total of 144 vancomycin concentrations were derived from 63 neonates in the external population. Five of the 28 models retained for evaluation were found predictive with a bias of 15% and an imprecision of 30%. Overall, the Grimsley and Thomson model performed best, with a bias of -0.8% and an imprecision of 20.9%; therefore, it was applied in the simulations. A novel initial dosing regimen of 15 mg/kg, followed by 11 mg/kg every 8 hours should favor therapeutic target attainment. CONCLUSIONS A predictive population pharmacokinetic model of vancomycin was identified after an external evaluation and used to recommend a novel initial dosing regimen. The implementation of these model-based tools may guide physicians in selecting the most appropriate initial vancomycin dose, leading to improved clinical outcomes.
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Affiliation(s)
- Mathieu Blouin
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Marie-Élaine Métras
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine, Montréal (QC), Canada; and
| | - Mehdi El Hassani
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Aysenur Yaliniz
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Amélie Marsot
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montréal (QC), Canada
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Taguchi Y, Toma K, Iitani K, Arakawa T, Iwasaki Y, Mitsubayashi K. In Vitro Performance of a Long-Range Surface Plasmon Hydrogel Aptasensor for Continuous and Real-Time Vancomycin Measurement in Human Serum. ACS APPLIED MATERIALS & INTERFACES 2024; 16:28162-28171. [PMID: 38767334 DOI: 10.1021/acsami.4c03805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
This study investigated the suitability of surface modification for a long-range surface plasmon (LRSP) aptasensor using two different hydrogels, aiming at real-time monitoring of vancomycin (VCM) in undiluted serum and blood. Three different layer structures were formed on a gold surface of LRSP sensor chip using poly[2-methacryloyloxyethyl phosphorylcholine (MPC)-co-N-methacryloyl-(L)-tyrosinemethylester (MAT)] (PMM) and poly[MPC-co-2-ethylhexyl methacrylate (EHMA)-co-MAT] (PMEM). The peptide aptamer for VCM was immobilized in PMM and PMEM via MAT. Among four differently prepared sensor chips, the LRSP hydrogel aptasensor with PMM, referred to as the PMM hydrogel, exhibited the highest sensor output and superior antifouling properties. Following the optimization of the PMM hydrogel preparation conditions, the shelf life of the PMM hydrogel was determined to exceed 2 weeks, and the same sensor chip could be used for 102 days without significant performance deterioration. The PMM hydrogel was then applied for VCM measurement in undiluted serum in vitro, where it demonstrated a limit of detection of 0.098 μM and a dynamic range of 0.18-100 μM, covering the therapeutic range. Additionally, the PMM hydrogel enabled the continuous measurement of various VCM concentrations in serum without rinsing and showed a concentration-dependent output in undiluted blood. These findings underscore the potential of the PMM hydrogel for real-time and direct monitoring of VCM in body fluids.
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Affiliation(s)
- Yui Taguchi
- Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Koji Toma
- College of Engineering, Shibaura Institute of Technology, 3-7-5 Toyosu, Koto-ku, Tokyo 135-8548, Japan
| | - Kenta Iitani
- Department of Biomedical Devices and Instrumentation, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-0062, Japan
| | - Takahiro Arakawa
- Department of Electric and Electronic Engineering, Tokyo University of Technology, 1404-1 Katakura, Hachioji City, Tokyo 192-0982, Japan
| | - Yasuhiko Iwasaki
- Faculty of Chemistry, Materials and Bioengineering, Kansai University, 3-3-35 Yamate-cho, Suita-shi, Osaka 564-8680, Japan
| | - Kohji Mitsubayashi
- Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
- Department of Biomedical Devices and Instrumentation, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo 101-0062, Japan
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Dinçel S, Demirpolat E. Evaluation of the appropriateness of vancomycin therapeutic drug monitoring in the intensive care unit with a clinical pharmacy approach, a cross-sectional study. Eur J Hosp Pharm 2024:ejhpharm-2023-004073. [PMID: 38834285 DOI: 10.1136/ejhpharm-2023-004073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 05/28/2024] [Indexed: 06/06/2024] Open
Abstract
OBJECTIVES Vancomycin, a glycopeptide antibiotic has antibacterial activity against Gram-positive bacteria and is frequently used in the intensive care unit (ICU). Inappropriate therapeutic drug monitoring (TDM) of vancomycin is a common problem encountered in hospital daily practice. The aim of this study was to evaluate the appropriateness of vancomycin trough-guided TDM in patients treated in the ICU using a clinical pharmacy approach. METHODS The study was conducted retrospectively in patients over 18 years old who had at least one vancomycin trough level and who had received intravenous (IV) vancomycin for ≥3 days between 1 November 2020 and 1 April 2022. The study included 137 patients. Patient demographics and relevant vancomycin TDM data were collected from medical records. The appropriateness of TDM was evaluated according to the criteria established based on the monitoring recommendations specified in consensus guidelines for therapeutic drug monitoring of vancomycin published by the American Society of Health-System Pharmacists (ASHP) in 2009 and 2020. RESULTS Of a total of 238 vancomycin trough levels measured in patients, 32.4% were collected at an inappropriate time. When patients were evaluated in terms of TDM appropriateness according to vancomycin level ranges (<10 µg/mL, 10-20 µg/mL and >20 µg/mL), we found the appropriate TDM was significantly higher in the therapeutic range (10-20 µg/mL) (p <0.001). Of the total 238 vancomycin trough concentrations taken from patients, 77 (32.4%) were measured at an inappropriate time. This caused dose withholding, wrong adjustments and therapy failure. The total TDM appropriateness of vancomycin was significantly higher in the therapeutic range defined as 10-20 µg/mL when evaluated based on 'TDM appropriateness criteria' (p <0.001). CONCLUSION Our study shows that appropriate vancomycin TDM increases the likelihood of achieving target trough concentrations. Involvement of clinical pharmacists in TDM management may prevent the development of adverse reactions by ensuring appropriate sampling time and appropriate interpretation of vancomycin levels.
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Affiliation(s)
- Sema Dinçel
- Clinical Pharmacy Department, Faculty of Pharmacy, Erciyes University, Kayseri, Turkey
| | - Eren Demirpolat
- Clinical Pharmacy Department, Faculty of Pharmacy, Erciyes University, Kayseri, Turkey
- Pharmacology Department, Faculty of Pharmacy, Erciyes University, Kayseri, Turkey
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Yang W, Zhang K, Chen Y, Fan Y, Zhang J. Is It Still Beneficial to Monitor the Trough Concentration of Vancomycin? A Quantitative Meta-Analysis of Nephrotoxicity and Efficacy. Antibiotics (Basel) 2024; 13:497. [PMID: 38927164 PMCID: PMC11200798 DOI: 10.3390/antibiotics13060497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
This study conducted a quantitative meta-analysis to investigate the association of vancomycin indicators, particularly area under the curve over 24 h (AUC24) and trough concentrations (Ctrough), and their relationship with both nephrotoxicity and efficacy. Literature research was performed in PubMed and Web of Science on vancomycin nephrotoxicity and efficacy in adult inpatients. Vancomycin Ctrough, AUC24, AUC24/minimum inhibitory concentration (MIC), nephrotoxicity evaluation and treatment outcomes were extracted. Logistic regression and Emax models were conducted, stratified by evaluation criterion for nephrotoxicity and primary outcomes for efficacy. Among 100 publications on nephrotoxicity, 29 focused on AUC24 and 97 on Ctrough, while of 74 publications on efficacy, 27 reported AUC24/MIC and 68 reported Ctrough. The logistic regression analysis indicated a significant association between nephrotoxicity and vancomycin Ctrough (odds ratio = 2.193; 95% CI 1.582-3.442, p < 0.001). The receiver operating characteristic curve had an area of 0.90, with a cut-off point of 14.55 mg/L. Additionally, 92.3% of the groups with a mean AUC24 within 400-600 mg·h/L showed a mean Ctrough of 10-20 mg/L. However, a subtle, non-statistically significant association was observed between the AUC24 and nephrotoxicity, as well as between AUC24/MIC and Ctrough concerning treatment outcomes. Our findings suggest that monitoring vancomycin Ctrough remains a beneficial and valuable approach to proactively identifying patients at risk of nephrotoxicity, particularly when Ctrough exceeds 15 mg/L. Ctrough can serve as a surrogate for AUC24 to some extent. However, no definitive cut-off values were identified for AUC24 concerning nephrotoxicity or for Ctrough and AUC24/MIC regarding efficacy.
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Affiliation(s)
- Wanqiu Yang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Kaiting Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yuancheng Chen
- Phase I Clinical Research Center, Huashan Hospital, Fudan University, Shanghai 200040, China;
| | - Yaxin Fan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai 200040, China; (W.Y.); (K.Z.)
- Key Laboratory of Clinical Pharmacology of Antibiotics, National Population and Family Planning Commission, Shanghai 200040, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
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Florczyk A, Krajcer A, Wójcik K, Lewandowska-Łańcucka J. Innovative Vancomycin-Loaded Hydrogel-Based Systems - New Opportunities for the Antibiotic Therapy. Int J Nanomedicine 2024; 19:3991-4005. [PMID: 38720939 PMCID: PMC11078026 DOI: 10.2147/ijn.s443051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
Purpose Surgical site infections pose a significant challenge for medical services. Systemic antibiotics may be insufficient in preventing bacterial biofilm development. With the local administration of antibiotics, it is easier to minimize possible complications, achieve drugs' higher concentration at the injured site, as well as provide their more sustained release. Therefore, the main objective of the proposed herein studies was the fabrication and characterization of innovative hydrogel-based composites for local vancomycin (VAN) therapy. Methods Presented systems are composed of ionically gelled chitosan particles loaded with vancomycin, embedded into biomimetic collagen/chitosan/hyaluronic acid-based hydrogels crosslinked with genipin and freeze-dried to serve in a flake/disc-like form. VAN-loaded carriers were characterized for their size, stability, and encapsulation efficiency (EE) using dynamic light scattering technique, zeta potential measurements, and UV-Vis spectroscopy, respectively. The synthesized composites were tested in terms of their physicochemical and biological features. Results Spherical structures with sizes of about 200 nm and encapsulation efficiencies reaching values of approximately 60% were obtained. It was found that the resulting particles exhibit stability over time. The antibacterial activity of the developed materials against Staphylococcus aureus was established. Moreover, in vitro cell culture study revealed that the surfaces of all prepared systems are biocompatible as they supported the proliferation and adhesion of the model MG-63 cells. In addition, we have demonstrated significantly prolonged VAN release while minimizing the initial burst effect for the composites compared to bare nanoparticles and verified their desired physicochemical features during swellability, and degradation experiments. Conclusion It is expected that the developed herein system will enable direct delivery of the antibiotic at an exposed to infections surgical site, providing drugs sustained release and thus will reduce the risk of systemic toxicity. This strategy would both inhibit biofilm formation and accelerate the healing process.
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Affiliation(s)
- Aleksandra Florczyk
- Faculty of Chemistry, Jagiellonian University, Kraków, Poland
- Doctoral School of Exact and Natural Sciences, Jagiellonian University, Kraków, Poland
| | - Aleksandra Krajcer
- Faculty of Chemistry, Jagiellonian University, Kraków, Poland
- Doctoral School of Exact and Natural Sciences, Jagiellonian University, Kraków, Poland
| | - Kinga Wójcik
- Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Kraków, Poland
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Liu H, Yang H, Guo X, Bai Y, SiRi G. Clinical benefits of therapeutic drug monitoring of vancomycin therapy in patients with postoperative intracerebral hemorrhage: a retrospective cohort study. Eur J Hosp Pharm 2024; 31:240-246. [PMID: 36207132 DOI: 10.1136/ejhpharm-2022-003455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE The objective of this study was to investigate the clinical efficacy and safety of conducting therapeutic drug monitoring (TDM) of vancomycin in patients with postoperative intracerebral haemorrhage. METHODS We conducted a retrospective analysis of 435 patients who experienced postoperative cerebral haemorrhage and were treated with vancomycin in the Department of Neurosurgery of Inner Mongolia Autonomous Region People's Hospital from January 2017 to December 2021. Patients were then matched using the propensity score matching method in a ratio of 1:1. Ninety-two pairs of cases were successfully matched, and the data before and after performing vancomycin TDM were analysed. RESULTS After PSM, the baseline data of the two groups were balanced. There were no significant differences in the 14-day mortality and length of hospital stay (p>0.05) between the two groups. Compared with the non-TDM group, the TDM group had a higher proportion of patients with normal white blood cells (83.7% vs 56.5%, p=0.000), neutrophil count (57.6% vs 25.0%, p=0.000) and attaining desirable reductions of 80% in procalcitonin (65.2% vs 10.9%, p=0.000) and C-reactive protein (78.3% vs 41.3%, p=0.000) levels. At US$15.82 per additional TDM, TDM significantly promoted patient outcomes, as seen in improvements in the proportion of patients attaining desirable levels of white blood cells, neutrophil count, procalcitonin and C-reactive protein. CONCLUSIONS Vancomycin TDM is a safe and effective approach for the treatment of patients with postoperative intracerebral haemorrhage. The empirical use of TDM of vancomycin significantly improved normal values of white blood cells and neutrophil count, achieved desirable reductions of 80% in procalcitonin and C-reactive protein, and reduced nephrotoxicity in patients with postoperative intracerebral haemorrhage.
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Affiliation(s)
- Huanhuan Liu
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
- Department of Pharmacy, Baotou Medical College, Baotou, Inner Mongolia, China
| | - Hongxin Yang
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
| | - Xiaobin Guo
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
| | - Yingchun Bai
- Department of Pharmacy, Baotou Medical College, Baotou, Inner Mongolia, China
| | - Guleng SiRi
- Department of Pharmacy, Inner Mongolia Autonomous Region People's Hospital, Hohhot, Inner Mongolia, China
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Yan Z, Li J, Hu Y, Zhang Y, Wu Y, Ju X, Cai C, Chen G, Sun C, Zhang R. MALDI-TOF MS combined with AUC method for tigecycline susceptibility testing in Escherichia coli. JAC Antimicrob Resist 2024; 6:dlad119. [PMID: 38455378 PMCID: PMC10919394 DOI: 10.1093/jacamr/dlad119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/19/2023] [Indexed: 03/09/2024] Open
Abstract
Objectives The wide spread of tet(X4) gene orthologues in the environment, food, poultry and humans is causing serious tigecycline resistance. Consequently, developing a fast and universal method to detect tigecycline resistance has become increasingly important. Methods During 2019-2022, 116 Escherichia coli isolates were obtained from nine provinces in China. All isolates were tested for their susceptibility to antimicrobial agents by the microdilution broth method and for the tet(X4) gene by PCR. Ten tet(X4)-positive E. coli isolates were used to confirm certain conditions, including the optimal incubation time, the optimal concentration of tigecycline, and the cut-off of the relative growth (RG) value. Results The optimal time and concentration of tigecycline for separation of susceptible and resistant isolates was 2 h and 4 mg/L, and the RG cut-off value was 0.4. We validated whether the experiment was feasible using 116 isolates of E. coli. The method yielded a susceptibility of 94.9% (95% CI: 81.4%-99.1%) and a specificity of 96.1% (95% CI: 88.3%-99.0%). Conclusions This research has shown that this optical antimicrobial susceptibility testing method can rapidly differentiate between susceptible and resistant phenotypes in isolates of E. coli. In the same range as the current gold-standard methods, the clinical turnaround time is reduced from 48 h to 2.5 h. The above results suggest that the method has splendid specificity and operationality.
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Affiliation(s)
- Zelin Yan
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiapin Li
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanyan Hu
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yanyan Zhang
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuchen Wu
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyang Ju
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chang Cai
- School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia
| | - Gongxiang Chen
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chengtao Sun
- Beijing Key Laboratory of Detection Technology for Animal Food Safety, College of Veterinary Medicine, China Agricultural University, Beijing, China
| | - Rong Zhang
- Department of Clinical Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Jung Y, Kim S, Kim MG, Lee YE, Shin MG, Yang S. One-Step Detection of Vancomycin in Whole Blood Using the Lateral Flow Immunoassay. BIOSENSORS 2024; 14:129. [PMID: 38534236 DOI: 10.3390/bios14030129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/24/2024] [Accepted: 02/26/2024] [Indexed: 03/28/2024]
Abstract
Vancomycin (VAN) is an effective antibiotic against Gram-positive bacteria and the first-line therapy to prevent and treat methicillin-resistant Staphylococcus aureus (MRSA) and severe infections. However, low concentrations of VAN can result in resistant strains. High doses of VAN can cause nephrotoxicity and ototoxicity; thus, VAN is a representative drug for which drug monitoring is recommended. Several methods have been proposed to detect VAN. Among them, lateral flow immunoassays (LFIAs) have advantages, such as simple and user-friendly operation, low sample volume requirement, and cost effectiveness. In this study, we developed an LFIA capable of rapid on-site detection such that the VAN concentration in plasma could be monitored within 20 min by a one-step detection process using whole blood without plasma separation. VAN can be detected in whole blood over a wide range of concentrations (20-10,000 ng/mL), and the LFIA reported here has a detection limit of 18 ng/mL. The applicability of the developed LFIA compared to the results of measuring VAN with a commercial enzyme-linked immunosorbent assay kit showed a satisfactory correlation (Spearman's rho, ρ = 0.891). Therefore, the developed LFIA enables rapid and wide-range VAN detection in whole blood and can aid in drug monitoring to evaluate patients' responses to treatment.
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Affiliation(s)
- Yugyung Jung
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology (GIST), Gwangju 61005, Republic of Korea
| | - Seonjong Kim
- Department of Chemistry, Gwangju Institute of Science and Technology (GIST), Gwangju 61005, Republic of Korea
| | - Min-Gon Kim
- Department of Chemistry, Gwangju Institute of Science and Technology (GIST), Gwangju 61005, Republic of Korea
- GMD Biotech, Inc., Gwangju 61005, Republic of Korea
| | - Young-Eun Lee
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital (CNUHH), Hwasun 58128, Republic of Korea
- Accelerator Platform of Precision Medicine, Chonnam National University Hwasun Hospital (CNUHH), Hwasun 58128, Republic of Korea
| | - Myung-Geun Shin
- Department of Laboratory Medicine, Chonnam National University Hwasun Hospital (CNUHH), Hwasun 58128, Republic of Korea
- Accelerator Platform of Precision Medicine, Chonnam National University Hwasun Hospital (CNUHH), Hwasun 58128, Republic of Korea
| | - Sung Yang
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology (GIST), Gwangju 61005, Republic of Korea
- School of Mechanical Engineering, Gwangju Institute of Science and Technology (GIST), Gwangju 61005, Republic of Korea
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Yoshida Y, Fukuda T, Fukuoka K, Nagayama T, Tanihara T, Nishikawa N, Otsuki K, Terada Y, Hamamura K, Oyama K, Tsuruta A, Mayanagi K, Koyanagi S, Matsunaga N, Ohdo S. Time-Dependent Differences in Vancomycin Sensitivity of Macrophages Underlie Vancomycin-Induced Acute Kidney Injury. J Pharmacol Exp Ther 2024; 388:218-227. [PMID: 38050132 DOI: 10.1124/jpet.123.001864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/21/2023] [Accepted: 11/07/2023] [Indexed: 12/06/2023] Open
Abstract
Although vancomycin (VCM)-frequently used to treat drug-resistant bacterial infections-often induces acute kidney injury (AKI), discontinuation of the drug is the only effective treatment; therefore, analysis of effective avoidance methods is urgently needed. Here, we report the differences in the induction of AKI by VCM in 1/2-nephrectomized mice depending on the time of administration. Despite the lack of difference in the accumulation of VCM in the kidney between the light (ZT2) and dark (ZT14) phases, the expression of AKI markers due to VCM was observed only in the ZT2 treatment. Genomic analysis of the kidney suggested that the time of administration was involved in VCM-induced changes in monocyte and macrophage activity, and VCM had time-dependent effects on renal macrophage abundance, ATP activity, and interleukin (IL)-1β expression. Furthermore, the depletion of macrophages with clodronate abolished the induction of IL-1β and AKI marker expression by VCM administration at ZT2. This study provides evidence of the need for time-dependent pharmacodynamic considerations in the prevention of VCM-induced AKI as well as the potential for macrophage-targeted AKI therapy. SIGNIFICANCE STATEMENT: There is a time of administration at which vancomycin (VCM)-induced renal injury is more and less likely to occur, and macrophages are involved in this difference. Therefore, there is a need for time-dependent pharmacodynamic considerations in the prevention of VCM-induced acute kidney injury as well as the potential for macrophage-targeted acute kidney injury therapy.
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Affiliation(s)
- Yuya Yoshida
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Taiki Fukuda
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohei Fukuoka
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshitaka Nagayama
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomohito Tanihara
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Naoki Nishikawa
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Kaita Otsuki
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuma Terada
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Kengo Hamamura
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Kosuke Oyama
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Akito Tsuruta
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Kota Mayanagi
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Satoru Koyanagi
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Naoya Matsunaga
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigehiro Ohdo
- Departments of Clinical Pharmacokinetics (Y.Y., T.F., T.N., T.T., N.N., K.O., Y.T., K.H., N.M.), Pharmaceutics (K.F., K.O., S.O.), Glocal Healthcare Science (A.T., S.K.), and Drug Discovery Structural Biology (K.M.), Faculty of Pharmaceutical Sciences, Kyushu University, Fukuoka, Japan
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12
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Haag H, Lau A. Correlation of Calculated Vancomycin Trough Concentrations and Exposure: A Monte Carlo Simulation. Ann Pharmacother 2023; 57:1410-1414. [PMID: 36999486 DOI: 10.1177/10600280231160571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Current recommendations are to dose vancomycin to target 24-hour area under the curve (AUC) of 400-600 mg·h/L to optimize efficacy and safety. Limited data support AUC monitoring, and some centers continue to use trough concentrations. A target of 10-20 mg/L has been proposed to reduce nephrotoxicity risk. OBJECTIVE To use previously published pharmacokinetic equations in a Monte Carlo simulation relating AUC exposure to trough concentrations when targeting an AUC between 400 and 600 mg·h/L. METHODS Previously published pharmacokinetic data were used as input parameters for a Monte Carlo simulation using previously published formulae to correlate AUC to simulated trough concentrations. Pharmacokinetic parameters were assumed to occur in a normal distribution pattern. We excluded irrelevant simulated cases. Maintenance doses of 15 mg/kg were rounded to the nearest 250 mg. Calculated trough concentrations for AUCs of both 400 and 600 mg·h/L were evaluated in each simulation. RESULTS A total of 10 000 Monte Carlo simulations were performed. Targeting an AUC of 400 mg·h/L resulted in a mean trough concentration of 10.3 ± 0.8 mg/L. Targeting an AUC of 600 mg·h/L resulted in a mean trough concentration of 15.4 ± 1.2 mg/L. CONCLUSION AND RELEVANCE We demonstrate that a lower trough concentration range may be supported by an AUC of 400-600 mg·h/L, which may reduce risk and rates of nephrotoxicity without compromising previously established efficacious target trough concentrations.
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Affiliation(s)
- Hans Haag
- Vancouver General Hospital, Vancouver, BC, Canada
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
| | - Anthony Lau
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, BC, Canada
- Emergency Medicine, Vancouver General Hospital, Vancouver, BC, Canada
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13
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Nolan J, McCarthy K, Farkas A, Avent ML. Feasibility of individualised patient modelling for continuous vancomycin infusions in outpatient antimicrobial therapy, a retrospective study. Int J Clin Pharm 2023; 45:1444-1451. [PMID: 37532840 DOI: 10.1007/s11096-023-01618-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/24/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter for dosing vancomycin continuous infusion in methicillin-resistant Staphylococcus aureus (MRSA) infection. Individualised pharmacokinetic-pharmacodynamic (PK/PD) calculation of AUC24 may better represent therapeutic dosing than current Therapeutic Drug Monitoring (TDM) practices, targeting a Steady State Concentration of 15-25 mg/L. AIM To compare real world TDM practice to theoretical, individualised, PK/PD target parameters utilising Bayesian predictions to steady state concentrations (Css) for outpatients on continuous vancomycin infusions. METHOD A retrospective single centre study was conducted at a tertiary hospital on adult patients, enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program, receiving vancomycin infusions for MRSA infection. Retrospective Bayesian dosing was modelled to target PK/PD parameters and compared to real world data. RESULTS Fifteen patients were evaluated with 53% (8/15) achieved target CSS during hospitalisation, and 83% (13/15) as outpatient. Median Bayesian AUC/MIC was 613 mg.h/L with CSS 25 mg/L. Patients suffering an Acute Kidney Injury (33%) had higher AUC0-24/MIC values. Retrospective Bayesian modelling demonstrated on median 250 mg/24 h lower doses than that administered was required (R2 = 0.81) which achieved AUC24/MIC median 444.8 (range 405-460) mg.h/L and CSS 18.8 (range 16.8-20.4) mg/L. CONCLUSION Bayesian modelling could assist in obtaining more timely target parameters at lower doses for patients receiving continuous vancomycin infusion as part of an OPAT program, which may beget fewer adverse effects. Utilisation of personalised predictive modelling may optimise vancomycin prescribing, achieving earlier target concentrations as compared to empiric dosing regimens.
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Affiliation(s)
- J Nolan
- The Royal Brisbane and Women's Hospital, Herston, Australia.
- School of Medicine, University of Queensland, 4029, Herston, Australia.
| | - K McCarthy
- The Royal Brisbane and Women's Hospital, Herston, Australia
- School of Medicine, University of Queensland, 4029, Herston, Australia
| | - A Farkas
- Mount Sinai West Hospital, New York, USA
- Optimum Dosing Strategies, Bloomingdale, New York, USA
| | - M L Avent
- The Royal Brisbane and Women's Hospital, Herston, Australia
- Queensland Statewide Antimicrobial Stewardship Program, University of Queensland Centre for Clinical Research, Herston, Australia
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14
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Wang J, Li Y, Huang S, Wang M, Jin L, Luo X, Cheng X, Yang N, Zhu H. Mid-dosing interval concentration is important for polymyxin B exposure and acute kidney injury in critically ill patients. CPT Pharmacometrics Syst Pharmacol 2023; 12:1911-1921. [PMID: 37655610 PMCID: PMC10725268 DOI: 10.1002/psp4.13040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/10/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023] Open
Abstract
This study aimed to evaluate the association between polymyxin B (PMB) exposure and acute kidney injury (AKI) and analyze the risk factors for PMB-induced AKI in critically ill patients. Plasma concentrations of PMB were determined using an ultraperformance liquid chromatography-tandem mass spectrometer in intensive care unit patients who were administered PMB. Univariate and multivariate analyses were conducted to identify risk factors. A receiver operating characteristic curve was constructed to assess the discriminant power of the factors and to identify the cutoff value for AKI. The white blood cell count and estimated area under the concentration-time curve (AUC) of patients administered PMB were independent risk factors for PMB-induced AKI, where AUC were calculated using a first-order pharmacokinetic equation based on the mid-dosing interval concentration (C1/2t ) and peak concentration. The area under the receiver operating characteristic curve of the final model was 0.805 (95% confidence interval, 0.690-0.921). The cutoff value for the combined predictor was 0.57. Alternatively, when using C1/2t , which was strongly correlated with AUC, as the only independent risk factor, the analysis showed that the 3.47 μg/ml threshold provides favorable differentiation between the AKI and non-AKI groups. These results provide insightful information for therapeutic drug monitoring-guiding PMB dosing in clinical practice.
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Affiliation(s)
- Jing Wang
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
| | - Yuanchen Li
- Department of PharmacyChina Pharmaceutical University Nanjing Drum Tower HospitalNanjingChina
| | - Siqi Huang
- Department of PharmacyNanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese MedicineNanjingChina
| | - Min Wang
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Lu Jin
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Xuemei Luo
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Xiaoliang Cheng
- Jiangsu Qlife Medical Technology Group Co., Ltd.NanjingChina
| | - Na Yang
- Department of PharmacyNanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical SchoolNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
| | - Huaijun Zhu
- Department of PharmacyNanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese MedicineNanjingChina
- Nanjing Medical Center for Clinical PharmacyNanjingChina
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15
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Tazerouni H, Labbani-Motlagh Z, Amini S, Shahrami B, Sajjadi-Jazi SM, Afhami S, Gholami K, Sadeghi K. Population pharmacokinetics of vancomycin in patients with diabetic foot infection: a comparison of five models. J Diabetes Metab Disord 2023; 22:1385-1390. [PMID: 37975097 PMCID: PMC10638227 DOI: 10.1007/s40200-023-01259-5] [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: 04/13/2023] [Accepted: 07/01/2023] [Indexed: 11/19/2023]
Abstract
Purpose This study aimed to compare individual pharmacokinetic (PK) parameters of vancomycin with predicted values from five population PK models in patients with diabetic foot infections (DFIs). Methods Patients with a diagnosis of DFI and an estimated glomerular filtration rate (eGFR) ≥ 30 mL/min were included in the study. Individual PK data was carried on by collecting three vancomycin serum concentrations in a steady-state condition. Five published population-based nomograms were assumed to predict PK parameters. Optimal vancomycin exposure was considered as a trough level of 15-20 mg/L or the area under the curve over 24 h/minimum inhibitory concentration (AUC24/MIC) ≥ 400. Results A total of 48 samples from 16 patients were analyzed. There was a statistically significant difference between the volume of distribution (Vd) obtained from population methods and the individual estimations (P ≤ 0.001 in Ambrose and Burton, P = 0.010 and 0.006 in Bauer and Burton revised models, respectively). AUC/MIC ≥ 400 was achieved in 68.7% of patients while 50% had a trough level of less than 15 mg/L. Conclusions Vancomycin PK parameters, particularly individualized Vd, may not be predictable by population nomograms in patients with DFI and stable renal function. Moreover, the weak correlation between AUC24 values and trough concentrations underlines the starting practice of vancomycin AUC24-based monitoring and dosing in the clinical setting.
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Affiliation(s)
- Hedieh Tazerouni
- Department of Clinical Pharmacy, International Campus, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Zohre Labbani-Motlagh
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahideh Amini
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Bita Shahrami
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Sayed Mahmoud Sajjadi-Jazi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirin Afhami
- Department of Infectious Disease, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kheirollah Gholami
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Kourosh Sadeghi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Morales Junior R, Juodinis VD, de Souza DC, Santos SRCJ. Pharmacokinetics and therapeutic target attainment of vancomycin in pediatric post-liver transplant patients. Braz J Infect Dis 2023; 27:103688. [PMID: 37977199 PMCID: PMC10698562 DOI: 10.1016/j.bjid.2023.103688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/26/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Vancomycin is widely prescribed to treat or prevent Gram-positive infections in pediatric liver transplant recipients. The objective of this prospective cohort study is to describe vancomycin pharmacokinetics and to evaluate the therapeutic target attainment after initial dose regimen. MATERIALS AND METHODS Patients with previous renal injury were excluded. Vancomycin therapy started with 40‒60 mg/kg/day. The pharmacokinetic parameters were assessed using two steady-state blood samples and the first-order kinetic equations. Therapeutic target was defined as vancomycin 24-hour Area Under the Curve/Minimum Inhibitory Concentration (AUC/MIC) ≥ 400 and < 600. RESULTS Sixteen patients were included. The found vancomycin clearance, half-life, and volume of distribution were, respectively: 2.1 (1.3‒2.8) mL/kg/min, 3.3 (2.7‒4.4) hours, and 0.7 (0.5‒0.9) L/kg. With the initial dose, only 6 (37 %) patients reached the therapeutic target against Gram-positive pathogens with MIC 1 mg/L. After individual dose adjustments, all patients reached the target. The correlation between trough levels and AUC was low (R2 = 0.5). CONCLUSIONS Pediatric patients with preserved renal function after liver transplantation have an increased volume of distribution for vancomycin, and most patients present subtherapeutic levels after the standard initial dosing regimen. With the vancomycin AUC-guided monitoring and dosing, it is possible to improve therapeutic target attainment.
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Affiliation(s)
- Ronaldo Morales Junior
- Universidade de São Paulo, Faculdade de Ciências Farmacêuticas, Centro de Farmacocinética Clínica, São Paulo, SP, Brazil; Hospital Sírio-libanês, Unidade Pediátrica, São Paulo, SP, Brazil.
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17
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Lim WXS, Seah XFV, Thoon KC, Han Z. Comparison of Vancomycin Trough-Based and 24-Hour Area Under the Curve Over Minimum Inhibitory Concentration (AUC/MIC)-Based Therapeutic Drug Monitoring in Pediatric Patients. J Pediatr Pharmacol Ther 2023; 28:430-438. [PMID: 38130493 PMCID: PMC10731924 DOI: 10.5863/1551-6776-28.5.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 10/07/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVES Vancomycin 24-hour area under the curve over minimum inhibitory concentration (AUC/MIC) monitoring has been recommended over trough-based monitoring in pediatric patients. This study compared the proportion of target attainment between vancomycin AUC/MIC and trough-based methods, and identified risk factors for subtherapeutic initial extrapolated targets. METHODS This was a retrospective, observational study conducted at KK Women's and Children's Hospital (KKH), Singapore. Patients aged 1 month to 18 years with stable renal function who received intravenous vancomycin between January 2014 and October 2017, with at least 2 vancomycin serum concentrations obtained after the first dose of vancomycin, were included. Using a pharmacokinetic software, namely Adult and Pediatric Kinetics (APK), initial extrapolated steady-state troughs and 24-hour AUC were determined by using a one-compartmental model. Statistical tests included Wilcoxon rank sum test, McNemar test, logistic regression, and classification and regression tree (CART) analysis. RESULTS Of the 82 pediatric patients included, a significantly larger proportion of patients achieved therapeutic targets when the AUC/MIC-based method (24, 29.3%) was used than with the trough-based method (9, 11.0%; p < 0.01). Patients with estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 or with age <13 years had an increased risk of obtaining subtherapeutic targets. However, empiric vancomycin doses of 60 mg/kg/day would be sufficient to achieve serum therapeutic targets, using the AUC/MIC-based method. CONCLUSION The AUC/MIC-based vancomycin monitoring may be preferred because a larger proportion of patients could achieve initial therapeutic targets. Future prospective studies with larger sample size will be required to determine the optimal vancomycin strategy for pediatric patients.
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Affiliation(s)
- Wan Xuan Selina Lim
- Department of Pharmacy (WXSL, XFVS), KK Women's and Children's Hospital, Singhealth, Singapore
| | - Xue Fen Valerie Seah
- Department of Pharmacy (WXSL, XFVS), KK Women's and Children's Hospital, Singhealth, Singapore
| | - Koh Cheng Thoon
- Department of Infectious Diseases (KCT), Pediatrics, KK Women's and Children's Hospital, Singhealth, Singapore
| | - Zhe Han
- Department of Pharmacy (ZH), National University of Singapore, Singapore
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18
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Deenen S, Fransen LFC, Jaspers TCC, Workum JD. Treatment implications of augmented renal clearance in a critically ill COVID-19 patient: A case report. Fundam Clin Pharmacol 2023; 37:1011-1015. [PMID: 37161707 DOI: 10.1111/fcp.12916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/23/2023] [Accepted: 05/09/2023] [Indexed: 05/11/2023]
Abstract
Augmented renal clearance (ARC) is a pathophysiological phenomenon that can occur in critically ill patients, leading to enhanced renal function. It is defined as a creatinine clearance of >130 mL/min/1.73 m2 . ARC can lead to subtherapeutic levels of renally cleared drugs and subsequent treatment failure. In COVID-19, it has only been described in the literature in a few cases. We present the case of a 38-year-old critically ill patient with COVID-19 who developed ARC with an initial clearance of 226 mL/min/1.73 m2 , persisting for 30 days. He required high doses of sedatives and neuromuscular blocking agents, as well as increased doses of vancomycin and dalteparin, to reach adequate serum levels. This case emphasizes the importance for clinicians to consider ARC in the dosing of all renally cleared drugs, including antibiotics, low molecular weight heparins, and sedatives, to prevent subtherapeutic drug levels and treatment failure.
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Affiliation(s)
- Susan Deenen
- Department of Intensive Care, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Laura F C Fransen
- Department of Intensive Care, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Tessa C C Jaspers
- Department of Pharmacy, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Jessica D Workum
- Department of Intensive Care, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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19
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Coulibaly B, Maire P, Guitton J, Pelletier S, Tangara M, Aulagner G, Goutelle S. Population Pharmacokinetics of Vancomycin in Patients Receiving Hemodialysis in a Malian and a French Center and Simulation of the Optimal Loading Dose. Ther Drug Monit 2023; 45:637-643. [PMID: 36750447 DOI: 10.1097/ftd.0000000000001065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 09/07/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Vancomycin dosing remains challenging in patients receiving intermittent hemodialysis, especially in developing countries, where access to therapeutic drug monitoring and model-based dose adjustment services is limited. The objectives of this study were to describe vancomycin population PK in patients receiving hemodialysis in a Malian and French center and examine the optimal loading dose of vancomycin in this setting. METHODS Population pharmacokinetic analysis was conducted using Pmetrics in 31 Malian and 27 French hemodialysis patients, having a total of 309 vancomycin plasma concentrations. Structural and covariate analyses were based on goodness-of-fit criteria. The final model was used to perform simulations of the vancomycin loading dose, targeting a daily area under the concentration-time curve (AUC) of 400-600 mg.h/L or trough concentration of 15-20 mg/L at 48 hours. RESULTS After 48 hours of therapy, 68% of Malian and 63% of French patients exhibited a daily AUC of <400. The final model was a 2-compartment model, with hemodialysis influencing vancomycin elimination and age influencing the vancomycin volume distribution. Younger Malian patients exhibited a lower distribution volume than French patients. Dosing simulation suggested that loading doses of 1500, 2000, and 2500 mg would be required to minimize underexposure in patients aged 30, 50, and 70 years, respectively. CONCLUSIONS In this study, a low AUC was frequently observed in hemodialysis patients in Mali and France after a standard vancomycin loading dose. A larger dose is necessary to achieve the currently recommended AUC target. However, the proposed dosing algorithm requires further clinical evaluation.
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Affiliation(s)
- Balla Coulibaly
- Univ Lyon, Université Claude Bernard Lyon 1, INSA Lyon, CNRS, MATEIS, UMR5510, Lyon, France
- Université des Sciences, des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Pascal Maire
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Univ Lyon, Université Claude Bernard Lyon 1, Faculté de Médecine Lyon Sud, Pierre-Bénite, France
| | - Jêrome Guitton
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon, Lyon, France
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Solenne Pelletier
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service de Néphrologie, Lyon, France
| | - Moustapha Tangara
- Centre Hospitalo-Universitaire du Point-G de Bamako, Service de Néphrologie, Lyon, France
| | - Gilles Aulagner
- Univ Lyon, Université Claude Bernard Lyon 1, INSA Lyon, CNRS, MATEIS, UMR5510, Lyon, France
- Académie Nationale de Pharmacie, Paris, France; and
| | - Sylvain Goutelle
- Univ Lyon, Université Claude Bernard Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Évolutive, Villeurbanne, France
- Univ Lyon, Université Claude Bernard Lyon 1, ISPB-Faculté de Pharmacie de Lyon, Lyon, France
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
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20
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Frymoyer A, Schwenk HT, Brockmeyer JM, Bio L. Impact of model-informed precision dosing on achievement of vancomycin exposure targets in pediatric patients with cystic fibrosis. Pharmacotherapy 2023; 43:1007-1014. [PMID: 37401162 DOI: 10.1002/phar.2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Vancomycin is commonly used to treat acute pulmonary exacerbations in pediatric patients with cystic fibrosis (CF) and a history of methicillin-resistant Staphylococcus aureus. Optimizing vancomycin exposure during therapy is essential and area under-the-curve (AUC)-guided dosing is now recommended. Model-informed precision dosing (MIPD) utilizing Bayesian forecasting is a powerful approach that can support AUC-guided dose individualization. The objective of the current study was to examine the impact of implementing an AUC-guided dose individualization approach supported via a MIPD clinical decision support (CDS) tool on vancomycin exposure, target attainment rate, and safety in pediatric patients with CF treated with vancomycin during clinical care. METHODS A retrospective chart review was performed in patients with CF at a single children's hospital comparing pre- and post-implementation of a MIPD approach for vancomycin supported by a cloud-based, CDS tool integrated into the electronic health record (EHR). In the pre-MIPD period, vancomycin starting doses of 60 mg/kg/day (<13 years) or 45 mg/kg/day (≥13 years) were used. Dose adjustment was guided by therapeutic drug monitoring (TDM) with a target trough 10-20 mg/L. In the post-MIPD period, starting dose and dose adjustment were based on the MIPD CDS tool predictions with a target 24 h AUC (AUC24 ) 400-600 mg*h/L. Exposure and target achievement rates were retrospectively calculated and compared. Rates of acute kidney injury (AKI) were also compared. RESULTS Overall, 23 patient courses were included in the pre-MIPD period and 21 patient courses in the post-MIPD period. In the post-MIPD period, an individualized MIPD starting dose resulted in 71% of patients achieving target AUC24 compared to 39% in the pre-MIPD period (p < 0.05). After the first TDM and dose adjustment, target AUC24 achievement was also higher post-MIPD versus pre-MIPD (86% vs. 57%; p < 0.05). AKI rates were low and similar between periods (pre-MIPD 8.7% vs. post-MIPD 9.5%; p = 0.9). CONCLUSION An MIPD approach implemented within a cloud-based, EHR-integrated CDS tool safely supported vancomycin AUC-guided dosing and resulted in high rates of target achievement.
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Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Hayden T Schwenk
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Jake M Brockmeyer
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Laura Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
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21
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Srour N, Lopez C, Succar L, Nguyen P. Vancomycin dosing in high-intensity continuous renal replacement therapy: A retrospective cohort study. Pharmacotherapy 2023; 43:1015-1023. [PMID: 37458062 DOI: 10.1002/phar.2852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION An inverse relationship exists between vancomycin serum concentrations and the intensity of continuous renal replacement therapy (CRRT), reflected through the dialysate flow rate (DFR). There remains a lack of evidence to guide initial vancomycin dosing in the setting of high-intensity CRRT (i.e., DFR >30 mL/kg/h). Additionally, recommendations for pharmacokinetic monitoring of vancomycin have transitioned from a trough-based to area under the curve (AUC)-based dosing strategy to optimize efficacy and safety. Therefore, an improved understanding of the impact of CRRT intensity on AUC/MIC (minimum inhibitory concentration) has the potential to enhance vancomycin dosing in this patient population. OBJECTIVES The goal of this study is to evaluate current vancomycin dosing strategies and achievement of pharmacokinetic targets in patients on high-intensity CRRT. METHODS This was a single-center, retrospective cohort study of adult critically ill patients admitted to Houston Methodist Hospital between May 2019 and October 2021 and received vancomycin therapy while on high-intensity CRRT. High-intensity CRRT was defined by a DFR that was both ≥3 L/h and >30 mL/kg/h. Depending on the initial vancomycin dosing strategy, patients were stratified into either the traditional (15 mg/kg/day) or enhanced (≥15 mg/kg/day) dosing group. The primary outcome was the percent of patients who attained steady-state AUC24 /MIC ≥400 mg*h/L at the first obtained vancomycin level in the enhanced group compared with the traditional group. RESULTS A total of 125 patients were included in the final analysis, 56 in the traditional and 69 in the enhanced dosing group. The primary end point occurred in 74% and 54% of patients in the enhanced and traditional dosing groups, respectively (p = 0.029). Therapeutic vancomycin trough levels (10-20 μg/mL) were more commonly achieved in the enhanced dosing group compared with the traditional dosing group (66.7% vs. 45%, p = 0.013). As DFR rose, increasingly higher doses of vancomycin, up to 27 mg/kg/day, were required to achieve the therapeutic targets. CONCLUSION This is the first study to evaluate the influence of variable CRRT intensities on vancomycin AUC/MIC. Our findings suggest that vancomycin doses of ≥15 mg/kg/day are needed to achieve early therapeutic targets in patients on high-intensity CRRT.
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Affiliation(s)
- Nina Srour
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Chelsea Lopez
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Luma Succar
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Peter Nguyen
- Houston Methodist Hospital, Houston, Texas, USA
- Houston Kidney Consultants, Houston, Texas, USA
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22
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Alnezary FS, Almutairi MS, Gonzales-Luna AJ, Thabit AK. The Significance of Bayesian Pharmacokinetics in Dosing for Critically Ill Patients: A Primer for Clinicians Using Vancomycin as an Example. Antibiotics (Basel) 2023; 12:1441. [PMID: 37760737 PMCID: PMC10525617 DOI: 10.3390/antibiotics12091441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Antibiotic use is becoming increasingly challenging with the emergence of multidrug-resistant organisms. Pharmacokinetic (PK) alterations result from complex pathophysiologic changes in some patient populations, particularly those with critical illness. Therefore, antibiotic dose individualization in such populations is warranted. Recently, there have been advances in dose optimization strategies to improve the utilization of existing antibiotics. Bayesian-based dosing is one of the novel approaches that could help clinicians achieve target concentrations in a greater percentage of their patients earlier during therapy. This review summarizes the advantages and disadvantages of current approaches to antibiotic dosing, with a focus on critically ill patients, and discusses the use of Bayesian methods to optimize vancomycin dosing. The Bayesian method of antibiotic dosing was developed to provide more precise predictions of drug concentrations and target achievement early in therapy. It has benefits such as the incorporation of personalized PK/PD parameters, improved predictive abilities, and improved patient outcomes. Recent vancomycin dosing guidelines emphasize the importance of using the Bayesian method. The Bayesian method is able to achieve appropriate antibiotic dosing prior to the patient reaching the steady state, allowing the patient to receive the right drug at the right dose earlier in therapy.
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Affiliation(s)
- Faris S. Alnezary
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 41477, Saudi Arabia;
| | - Masaad Saeed Almutairi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim 51452, Saudi Arabia
| | - Anne J. Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX 77204, USA;
| | - Abrar K. Thabit
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah 21589, Saudi Arabia;
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23
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Lin P, Hua J, Teng Z, Lin C, Liu S, He R, Chen H, Yao H, Ye J, Zhu G. Screening of hub inflammatory bowel disease biomarkers and identification of immune-related functions based on basement membrane genes. Eur J Med Res 2023; 28:247. [PMID: 37481583 PMCID: PMC10362583 DOI: 10.1186/s40001-023-01193-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 06/23/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a chronic, inflammatory, and autoimmune disease, but its specific etiology and pathogenesis are still unclear. This study aimed to better discover the causative basement membrane (BM) genes of their subtypes and their associations. METHODS The differential expression of BM genes between CD and UC was analyzed and validated by downloading relevant datasets from the GEO database. We divided the samples into 3 groups for comparative analysis. Construction of PPI networks, enrichment of differential gene functions, screening of Lasso regression models, validation of ROC curves, nomogram for disease prediction and other analytical methods were used. The immune cell infiltration was further explored by ssGSEA analysis, the immune correlates of hub BM genes were found, and finally, the hub central genes were screened by machine learning. RESULTS We obtained 6 candidate hub BM genes related to cellular immune infiltration in the CD and UC groups, respectively, and further screened the central hub genes ADAMTS17 and ADAMTS9 through machine learning. And in the ROC curve models, AUC > 0.7, indicating that this characteristic gene has a more accurate predictive effect on IBD. We also found that the pathogenicity-related BM genes of the CD and UC groups were mainly concentrated in the ADAMTS family (ADAMTS17 and ADAMTS9). Addition there are some differences between the two subtypes, and the central different hub BM genes are SPARC, POSTN, and ADAMTS2. CONCLUSIONS In the current study, we provided a nomogram model of CD and UC composed of BM genes, identified central hub genes, and clarified the similarities and differences between CD and UC. This will have potential value for preclinical, clinical, and translational guidance and differential research in IBD.
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Affiliation(s)
- Penghang Lin
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Jin Hua
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Zuhong Teng
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Chunlin Lin
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Songyi Liu
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Ruofan He
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Hui Chen
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Hengxin Yao
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, 350000, China
| | - Jianxin Ye
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China.
| | - Guangwei Zhu
- Department of Gastrointestinal Surgery 2 Section, Institute of Abdominal Surgery, Key Laboratory of Accurate Diagnosis and Treatment of Cancer, The First Affiliated Hospital of Fujian Medical University, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, 20th, Chazhong Road, Fuzhou, 350005, Fujian, China.
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Del Valle-Moreno P, Suarez-Casillas P, Mejías-Trueba M, Ciudad-Gutiérrez P, Guisado-Gil AB, Gil-Navarro MV, Herrera-Hidalgo L. Model-Informed Precision Dosing Software Tools for Dosage Regimen Individualization: A Scoping Review. Pharmaceutics 2023; 15:1859. [PMID: 37514045 PMCID: PMC10386689 DOI: 10.3390/pharmaceutics15071859] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Pharmacokinetic nomograms, equations, and software are considered the main tools available for Therapeutic Drug Monitoring (TDM). Model-informed precision dosing (MIPD) is an advanced discipline of TDM that allows dose individualization, and requires a software for knowledge integration and statistical calculations. Due to its precision and extensive applicability, the use of these software is widespread in clinical practice. However, the currently available evidence on these tools remains scarce. OBJECTIVES To review and summarize the available evidence on MIPD software tools to facilitate its identification, evaluation, and selection by users. METHODS An electronic literature search was conducted in MEDLINE, EMBASE, OpenAIRE, and BASE before July 2022. The PRISMA-ScR was applied. The main inclusion criteria were studies focused on developing software for use in clinical practice, research, or modelling. RESULTS Twenty-eight software were classified as MIPD software. Ten are currently unavailable. The remaining 18 software were described in depth. It is noteworthy that all MIPD software used Bayesian statistical methods to estimate drug exposure and all provided a population model by default, except NONMEN. CONCLUSIONS Pharmacokinetic software have become relevant tools for TDM. MIPD software have been compared, facilitating its selection for use in clinical practice. However, it would be interesting to standardize the quality and validate the software tools.
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Affiliation(s)
- Paula Del Valle-Moreno
- Department of Pharmacy, University Hospital Virgen del Rocío, 41013 Seville, Spain; (P.D.V.-M.); (P.S.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
| | - Paloma Suarez-Casillas
- Department of Pharmacy, University Hospital Virgen del Rocío, 41013 Seville, Spain; (P.D.V.-M.); (P.S.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
| | - Marta Mejías-Trueba
- Department of Pharmacy, University Hospital Virgen del Rocío, 41013 Seville, Spain; (P.D.V.-M.); (P.S.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Department of Infectious Diseases, Microbiology and Parasitology, Infectious Diseases Research Group, Institute of Biomedicine of Seville, University of Seville/Spanish National Research Council/University Hospital Virgen del Rocio, 41013 Seville, Spain
| | - Pablo Ciudad-Gutiérrez
- Department of Pharmacy, University Hospital Virgen del Rocío, 41013 Seville, Spain; (P.D.V.-M.); (P.S.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
| | - Ana Belén Guisado-Gil
- Department of Pharmacy, University Hospital Virgen del Rocío, 41013 Seville, Spain; (P.D.V.-M.); (P.S.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Department of Infectious Diseases, Microbiology and Parasitology, Infectious Diseases Research Group, Institute of Biomedicine of Seville, University of Seville/Spanish National Research Council/University Hospital Virgen del Rocio, 41013 Seville, Spain
- Centre for Biomedical Research Network on Infectious Diseases, 28029 Madrid, Spain
| | - María Victoria Gil-Navarro
- Department of Pharmacy, University Hospital Virgen del Rocío, 41013 Seville, Spain; (P.D.V.-M.); (P.S.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Department of Infectious Diseases, Microbiology and Parasitology, Infectious Diseases Research Group, Institute of Biomedicine of Seville, University of Seville/Spanish National Research Council/University Hospital Virgen del Rocio, 41013 Seville, Spain
- Centre for Biomedical Research Network on Infectious Diseases, 28029 Madrid, Spain
| | - Laura Herrera-Hidalgo
- Department of Pharmacy, University Hospital Virgen del Rocío, 41013 Seville, Spain; (P.D.V.-M.); (P.S.-C.); (P.C.-G.); (A.B.G.-G.); (M.V.G.-N.); (L.H.-H.)
- Department of Infectious Diseases, Microbiology and Parasitology, Infectious Diseases Research Group, Institute of Biomedicine of Seville, University of Seville/Spanish National Research Council/University Hospital Virgen del Rocio, 41013 Seville, Spain
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25
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Chang J, Tasellari A, Wagner JL, Scheetz MH. Contemporary pharmacologic treatments of MRSA for hospitalized adults: rationale for vancomycin versus non-vancomycin therapies as first line agents. Expert Rev Anti Infect Ther 2023; 21:1309-1325. [PMID: 37876291 DOI: 10.1080/14787210.2023.2275663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/23/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in the hospital setting and causes significant morbidity and mortality each year. Since the initial discovery over 60 years ago, vancomycin has remained a first-line treatment for many different types of MRSA infections. However, significant concerns related to target attainment and nephrotoxicity have spurred efforts to develop more effective agents in the last two decades. AREAS COVERED Newer anti-MRSA antibiotics that have been approved since 2000 include linezolid, daptomycin, and ceftaroline. As clinical evidence has accumulated, these newer agents have become more frequently used, and some are now recommended as co-first-line options (along with vancomycin) in clinical practice guidelines. For this review, a scoping review of the literature was conducted to support our findings and recommendations. EXPERT OPINION Vancomycin remains an important standard of care for MRSA infections but is limited with respect to nephrotoxicity and rapid target attainment. Newer agents such as linezolid, daptomycin, and ceftaroline have specific indications for treating different types of MRSA infections; however, newer agents also have unique attributes which require consideration during therapy.
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Affiliation(s)
- Jack Chang
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
| | - Ardita Tasellari
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
| | - Jamie L Wagner
- School of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
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26
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Bradley N, Ng K. Evaluation of Real-World Vancomycin Dosing and Attainment of Therapeutic Drug Monitoring Targets. PHARMACY 2023; 11:95. [PMID: 37368421 DOI: 10.3390/pharmacy11030095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/08/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023] Open
Abstract
In 2020, the Infectious Diseases Society of America (IDSA) recommended a change in vancomycin therapeutic drug monitoring from trough-based to AUC/MIC-based to optimize vancomycin's efficacy and reduce nephrotoxicity. Many hospitals have not implemented this change due to barriers such as the cost of AUC/MIC software and lack of provider familiarity. The purpose of this study was to determine the rate of AUC/MIC ratio target attainment using current trough-based vancomycin dosing practices at a city hospital. The rates of acute kidney injury (AKI) were also evaluated. Vancomycin orders were reviewed retrospectively to determine the expected AUC/MIC ratios using first-order pharmacokinetic equations over a 7-month period. Orders were excluded if they were written for a one-time dose, for individuals less than 18 years of age, or for those on hemodialysis. A total of 305 vancomycin orders were included in this review. Overall, 27.9% (85/305) of vancomycin orders attained the AUC/MIC ratio target of 400-600 mg·h/L as recommended by the guidelines. Nearly 35% (106/305) achieved AUC/MIC ratios below 400 mg·h/L and 37.4% (114/305) achieved AUC/MIC ratios above 600 mg·h/L. Orders for obese patients were significantly more likely to have below the target AUC/MIC ratios (68% vs. 23.9%, X2 48.48, p < 0.00001) and non-obese patients were significantly more likely to have above the target AUC/MIC ratios (45.7% vs. 12%, X2 27.36, p < 0.00001). The overall rate of acute kidney injury observed was 2.6%. Most vancomycin orders did not attain therapeutic drug monitoring targets, reflecting the ongoing clinical challenge of optimizing vancomycin doses and implementing new guideline recommendations.
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Affiliation(s)
- Nicole Bradley
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, USA
| | - Kimberly Ng
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, USA
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Alzahrani AM, Naeem A, AlAzmi A, Hakami AY, Karim S, Ali AS, Kamel FO, Alzhrani RM, Alkhaldi TS, Maghrabi LA, Alshehri NF, Alzahrani YA. Altered Pharmacokinetics Parameters of Vancomycin in Patients with Hematological Malignancy with Febrile Neutropenia, a Bayesian Software Estimation. Antibiotics (Basel) 2023; 12:979. [PMID: 37370298 DOI: 10.3390/antibiotics12060979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023] Open
Abstract
The pharmacokinetics of vancomycin vary significantly between specific groups of patients, such as critically ill patients and patients with hematological malignancy (HM) with febrile neutropenia (FN). Recent evidence suggests that the use of the usual standard dose of antibiotics in patients with FN may not offer adequate exposure due to pharmacokinetic variability (PK). Therefore, the purpose of this study is to assess the effect of FN on AUC0-24 as a key parameter for vancomycin monitoring, as well as to determine which vancomycin PK parameters are affected by the presence of FN using Bayesian software PrecisePK in HM with FN. This study was carried out in King Abdulaziz Medical City. All adult patients who were admitted to the Princess Norah Oncology Center PNOC between 1 January and 2017 and 31 December 2020, hospitalized and received vancomycin with a steady-state trough concentration measured before the fourth dose, were included. During the trial period, 297 patients received vancomycin during their stay at the oncology center, 217 of them meeting the inclusion criteria. Pharmacokinetic parameters were estimated for the neutropenic and non-FN patients using the precise PK Bayesian platform. The result showed that there was a significant difference (p < 0.05) in vancomycin clearance Clvan, the volume of distribution at a steady-state Vdss, the volume of distribution for peripheral compartment Vdp, half-life for the elimination phase t½β, and the first-order rate constant for the elimination process β in FN compared to non-FN patients. Furthermore, AUC0-24 was lower for FN patients compared to non-FN patients, p < 0.05. FN has a significant effect on the PK parameters of vancomycin and AUC0-24, which may require specific consideration during the treatment initiation.
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Affiliation(s)
- Abdullah M Alzahrani
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Anjum Naeem
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Aeshah AlAzmi
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Alqassem Y Hakami
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Shahid Karim
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ahmed S Ali
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Fatemah Omer Kamel
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Rami M Alzhrani
- Department of Pharmaceutics and Industrial Pharmacy, College of Pharmacy, Taif University, Taif 21944, Saudi Arabia
| | - Teaf S Alkhaldi
- College of Pharmacy, Taif University, Taif 21944, Saudi Arabia
| | | | - Norah F Alshehri
- Department of Pharmacy, East Jeddah Hospital, Ministry of Health, Jeddah 22253, Saudi Arabia
| | - Yahya A Alzahrani
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- Department of Pharmacy, East Jeddah Hospital, Ministry of Health, Jeddah 22253, Saudi Arabia
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Belz SN, Seabury RW, Steele JM, Darko W, Miller CD, Probst LA, Kufel WD. Accuracy of 4 Free Online Dosing Calculators in Predicting the Vancomycin Area Under the Concentration-Time Curve Calculated Using a 2-Point Pharmacokinetic Approach. Ann Pharmacother 2023; 57:432-440. [PMID: 35979912 DOI: 10.1177/10600280221117256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Free online adaptive vancomycin dosing calculators are available to estimate area under the concentration-time curve (AUC), but the accuracy of predicting vancomycin AUC using these calculators compared with using a 2-point pharmacokinetic approach has not been described. OBJECTIVE To evaluate the accuracy of calculator-predicted AUC (cpAUC) using 4 free online calculators compared with reference AUC (rAUC), and to assess pharmacists' impressions of the ease of use. METHODS Vancomycin AUC was estimated using (1) the reference method via the Sawchuk-Zaske method and linear-logarithmic trapezoidal rule using 2 steady-state postdistributional vancomycin serum concentrations and (2) 4 free online vancomycin dosing calculators including ClinCalc, VancoPK, TDMx, and DMC. Accuracy was calculated by dividing cpAUC by rAUC. Ease of cpAUC estimation was determined by using a 10-point Likert scale. RESULTS All 4 calculators had a median cpAUC accuracy ranging from 89% to 110%. Concordance between cpAUC and rAUC determinations of AUC <400 and > 600 mg·h/L occurred 63.3% to 71.4% and 74.5% to 78.6% of the time, respectively. Pharmacist investigators agreed that ClinCalc and VancoPK calculators were easiest to use. CONCLUSION AND RELEVANCE cpAUC accuracy varied among the 4 calculators, but all consistently identified patients with an rAUC <400 mg·h/L and an rAUC > 600 mg·h/L at comparable frequencies. All 4 calculators demonstrated some imprecision based on their wide 95% CIs and potential inaccuracies in predicting an rAUC <400 mg·h/L or an rAUC > 600 mg·h/L. Clin Calc and VancoPK were most user friendly based on our pharmacists' impressions.
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Affiliation(s)
- Sarah N Belz
- Children's National Hospital, Washington, DC, USA
| | - Robert W Seabury
- State University of New York Upstate University Hospital, Syracuse, NY, USA.,State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey M Steele
- State University of New York Upstate University Hospital, Syracuse, NY, USA.,State University of New York Upstate Medical University, Syracuse, NY, USA
| | - William Darko
- State University of New York Upstate University Hospital, Syracuse, NY, USA.,State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Christopher D Miller
- State University of New York Upstate University Hospital, Syracuse, NY, USA.,State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Luke A Probst
- State University of New York Upstate University Hospital, Syracuse, NY, USA.,State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Wesley D Kufel
- State University of New York Upstate University Hospital, Syracuse, NY, USA.,State University of New York Upstate Medical University, Syracuse, NY, USA.,Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
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29
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Sujjavorakul K, Katip W, Kerr SJ, Wacharachaisurapol N, Puthanakit T. Predicting the Area under the Plasma Concentration-Time Curve (AUC) for First Dose Vancomycin Using First-Order Pharmacokinetic Equations. Antibiotics (Basel) 2023; 12:antibiotics12040630. [PMID: 37106993 PMCID: PMC10135334 DOI: 10.3390/antibiotics12040630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
To treat critically ill patients, early achievement of the target area under the plasma concentration-time curve/minimum inhibitory concentration (AUC/MIC) in the first 24 h is recommended. However, accurately calculating the AUC before steady state is an obstacle to this goal. A first-order pharmacokinetic equation to calculate vancomycin AUC after a first dose of vancomycin has never been studied. We sought to estimate AUC using two first-order pharmacokinetic equations, with different paired concentration time points, and to compare these to the actual first dose vancomycin AUC calculated by the linear-log trapezoid rule as a reference. The equations were validated using two independent intensive first dose vancomycin concentration time data sets, one from 10 adults and another from 14 children with severe infection. The equation with compensation for the alpha distribution phase using a first vancomycin serum concentration from 60 to 90 min and the second concentration from 240 to 300 min after the completed infusion showed good agreement and low bias of calculated AUC, with mean differences <5% and Lin's correlation coefficient >0.96. Moreover, it gave an excellent correlation with Pearson's r > 0.96. Estimating the first dose vancomycin AUC calculated using this first-order pharmacokinetic equation is both reliable and reproducible in clinical practice settings.
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Affiliation(s)
- Kritsaporn Sujjavorakul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Critical Care Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand
| | - Wasan Katip
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai 50200, Thailand
- Epidemiology Research Group of Infectious Disease (ERGID), Chiang Mai University, Chiang Mai 50200, Thailand
| | - Stephen J Kerr
- Biostatistics Centre, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- The Kirby Institute, The University of New South Wales, Kensington, NSW 2052, Australia
- HIV-NAT, The Thai Red Cross AIDS Research Centre, Bangkok 10330, Thailand
| | - Noppadol Wacharachaisurapol
- Center of Excellence in Clinical Pharmacokinetics and Pharmacogenomics, Department of Pharmacology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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Development of a Therapeutic Drug Monitoring Strategy for the Optimization of Vincristine Treatment in Pediatric Oncology Populations in Africa. Ther Drug Monit 2023; 45:354-363. [PMID: 36917736 DOI: 10.1097/ftd.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Recent studies have reported ethnic differences in vincristine exposure and outcomes such as toxicity. This resulted in the hypothesis of subtherapeutic dosing in African children. To optimize individual treatment, a strategy to identify subtherapeutic exposure using therapeutic drug monitoring is essential. The aim of the current study was to develop a strategy for therapeutic drug monitoring of vincristine in African children to meet the following criteria: (1) identify patients with low vincristine exposure with sufficient sensitivity (>70%), (2) determine vincristine exposure with a limited sampling strategy design of 3 samples, and (3) allow all samples to be collected within 4 hours after administration. METHODS An in silico simulation study was performed using a previously described population pharmacokinetic model and real-life demographic dataset of Kenyan and Malawian pediatric oncology patients. Two different therapeutic drug monitoring strategies were evaluated: (1) Bayesian approach and (2) pharmacometric nomogram. The sampling design was optimized using the constraints described above. Sensitivity analysis was performed to investigate the influence of missing samples, erroneous sampling times, and different boundaries on the nomogram weight bands. RESULTS With the Bayesian approach, 43.3% of the estimated individual exposure values had a prediction error of ≥20% owing to extremely high shrinkage. The Bayesian approach did not improve with alternative sampling designs within sampling constraints. However, the pharmacometric nomogram could identify patients with low vincristine exposure with a sensitivity, specificity, and accuracy of 75.1%, 76.4%, and 75.9%, respectively. The pharmacometric nomogram performed similarly for different weight bands. CONCLUSIONS The pharmacometric nomogram was able to identify patients with low vincristine exposure with high sensitivity, with 3 blood samples collected at 1, 1.5, and 4 hours after administration. Missing samples should be avoided, and the 3 scheduled samples should be collected within 15, 5, and 15 minutes of 1, 1.5, and 4 hours after administration, respectively.
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31
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Pi MY, Cai CJ, Zuo LY, Zheng JT, Zhang ML, Lin XB, Chen X, Zhong GP, Xia YZ. Population pharmacokinetics and limited sampling strategies of polymyxin B in critically ill patients. J Antimicrob Chemother 2023; 78:792-801. [PMID: 36702748 DOI: 10.1093/jac/dkad012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/02/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To characterize the pharmacokinetics (PK) of polymyxin B in Chinese critically ill patients. The factors significantly affecting PK parameters are identified, and a limited sampling strategy for therapeutic drug monitoring of polymyxin B is explored. METHODS Thirty patients (212 samples) were included in a population PK analysis. A limited sampling strategy was developed using Bayesian estimation, multiple linear regression and modified integral equations. Non-linear mixed-effects models were developed using Phoenix NLME software. RESULTS A two-compartment population PK model was used to describe polymyxin B PK. Population estimates of the volumes of central compartment distribution (V) and peripheral compartment distribution (V2), central compartment clearance (CL) and intercompartmental clearance (Q) were 7.857 L, 12.668 L, 1.672 L/h and 7.009 L/h. Continuous renal replacement therapy (CRRT) significantly affected CL, and body weight significantly affected CL and Q. The AUC0-12h of polymyxin B in patients with CRRT was significantly lower than in patients without CRRT. CL and Q increased with increasing body weight. A limited sampling strategy was suggested using a two-sample scheme with plasma at 0.5h and 8h after the end of infusion (C0.5 and C8) for therapeutic drug monitoring in the clinic. CONCLUSIONS A dosing regimen should be based on body weight and the application of CRRT. A two-sample strategy for therapeutic drug monitoring could facilitate individualized treatment with polymyxin B in critically ill patients.
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Affiliation(s)
- Meng-Ying Pi
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Chang-Jie Cai
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ling-Yun Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jun-Tao Zheng
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Miao-Lun Zhang
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China.,School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Bin Lin
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
| | - Guo-Ping Zhong
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-Sen University, Guangzhou, China
| | - Yan-Zhe Xia
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-Sen University, No. 58, Zhongshan 2nd Road, 510080, Guangzhou, China
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32
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Toma K, Satomura Y, Iitani K, Arakawa T, Mitsubayashi K. Long-range surface plasmon aptasensor for label-free monitoring of vancomycin. Biosens Bioelectron 2023; 222:114959. [PMID: 36502716 DOI: 10.1016/j.bios.2022.114959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/20/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022]
Abstract
Vancomycin (VCM) causes poisoning symptoms at high concentrations; thus, therapeutic drug monitoring is recommended to measure and control blood levels regularly. However, blood analysis at regular intervals does not allow knowing the detailed temporal change in concentration. To address this challenge, we developed a long-range surface plasmon (LRSP) aptasensor for measuring VCM label-free and real-time by combining a sensitive LRSP sensor and a peptide aptamer with a VCM recognition site. First, three different biosensors for VCM were compared. One was prepared by immobilizing the peptide aptamer directly on (Direct-Apt) or via a self-assembled monolayer (SAM) on a gold surface (SAM-Apt). The other used anti-VCM antibodies immobilized on a gold surface via the SAM (SAM-Ab). The Direct-Apt showed larger sensor output to VCM than the other biosensors. The dynamic range for VCM was 0.78-100 μM, including the therapeutic range (6.9-13.8 μM). The Direct-Apt also showed the sensor output only from VCM among four different antibiotics, demonstrating the high selectivity for VCM. The VCM captured by the aptamer could be removed by rinsing with phosphate-buffered saline. The measurement was rapid, with 72- and 77-sec response and recovery times, allowing not only repeated but also real-time measurements. Finally, the Direct-Apt in 20% serum solutions showed comparable sensitivity to VCM in the buffer solution, indicating high capability for real-sample.
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Affiliation(s)
- Koji Toma
- Department of Biomedical Devices and Instrumentation, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-0062, Japan; Department of Electronic Engineering, Shibaura Institute of Technology, 3-7-5 Toyosu, Koto-ku, Tokyo, 135-8548, Japan
| | - Yui Satomura
- Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Kenta Iitani
- Department of Biomedical Devices and Instrumentation, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-0062, Japan
| | - Takahiro Arakawa
- Department of Electric and Electronic Engineering, Tokyo University of Technology, 1404-1 Katakura, Hachioji City, Tokyo, 192-0982, Japan
| | - Kohji Mitsubayashi
- Department of Biomedical Devices and Instrumentation, Institute of Biomaterials and Bioengineering, Tokyo Medical and Dental University, 2-3-10 Kanda-Surugadai, Chiyoda-ku, Tokyo, 101-0062, Japan; Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
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Impact of Pharmacist-Led Multidisciplinary Team to Attain Targeted Vancomycin Area under the Curved Monitoring in a Tertiary Care Center in Thailand. Antibiotics (Basel) 2023; 12:antibiotics12020374. [PMID: 36830284 PMCID: PMC9952732 DOI: 10.3390/antibiotics12020374] [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: 01/05/2023] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Vancomycin Area Under the Curve (AUC) monitoring has been recommended to ensure successful clinical outcomes and minimize the risk of nephrotoxicity, rather than traditional trough concentration. However, vancomycin AUC monitoring by a pharmacist-led multidisciplinary team (PMT) has not been well established in Southeast Asia. This study was conducted at Thammasat University Hospital. Adult patients aged ≥ 18 years who were admitted and received intravenous vancomycin ≥48 h were included. The pre-PMT period (April 2020-September 2020) was defined as a period using traditional trough concentration, while the post-PMT period (October 2020-March 2021) was defined as a period using PMT to monitor vancomycin AUC. The primary outcome was the rate of achievement of the therapeutic target of an AUC/MIC ratio of 400-600. There was a significantly higher rate of achievement of therapeutic target vancomycin AUC during post-PMT period (66.7% vs. 34.3%, p < 0.001). Furthermore, there was a significant improvement in the clinical cure rate (92.4% vs. 69.5%, p < 0.001) and reduction in 30-day ID mortality (2.9% vs. 12.4%, p = 0.017) during the post-PMT period. Our study demonstrates that PMT was effective to help attain a targeted vancomycin AUC, improve the clinical cure rate, and reduce 30-day ID mortality. This intervention should be encouraged to be implemented in Southeast Asia.
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Huang J, Chan JD, Nguyen T, Jain R, Escobar ZK. Doing More With Less: Pragmatic Implementation of Vancomycin Area-Under-the-Curve (AUC) Monitoring. J Pharm Pract 2023; 36:10-14. [PMID: 34159816 DOI: 10.1177/08971900211027271] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Universal area-under-the-curve (AUC) guided vancomycin therapeutic drug monitoring (TDM) is resource-intensive, cost-prohibitive, and presents a paradigm shift that leaves institutions with the quandary of defining the preferred and most practical method for TDM. We report a step-by-step quality improvement process using 4 plan-do-study-act (PDSA) cycles to provide a framework for development of a hybrid model of trough and AUC-based vancomycin monitoring. We found trough-based monitoring a pragmatic strategy as a first-tier approach when anticipated use is short-term. AUC-guided monitoring was most impactful and cost-effective when reserved for patients with high-risk for nephrotoxicity. We encourage others to consider quality improvement tools to locally adopt AUC-based monitoring.
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Affiliation(s)
- Joanne Huang
- Department of Pharmacy Services, 2348Massachusetts General Hospital, Boston, MA, USA
| | - Jeannie D Chan
- Department of Pharmacy Services, UW Medicine, 21618Harborview Medical Center, Seattle, WA, USA.,21616University of Washington School of Pharmacy, Seattle, WA, USA
| | - Thu Nguyen
- Department of Pharmacy Services, 21616UW Medicine, Valley Medical Center, Renton, WA, USA
| | - Rupali Jain
- 21616University of Washington School of Pharmacy, Seattle, WA, USA.,Department of Pharmacy Services, UW Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Zahra Kassamali Escobar
- 21616University of Washington School of Pharmacy, Seattle, WA, USA.,Department of Pharmacy Services, 21616UW Medicine, Valley Medical Center, Renton, WA, USA
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35
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Chanapiwat P, Paiboonvong T, Rattanaumpawan P, Montakantikul P. Comparison of the mathematical equation and trapezoidal approach for 24 h area under the plasma concentration-time curve calculation in patients who received intravenous vancomycin in an acute care setting. Pharmacol Res Perspect 2023; 11:e01046. [PMID: 36588162 PMCID: PMC9806189 DOI: 10.1002/prp2.1046] [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] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/11/2022] [Indexed: 01/03/2023] Open
Abstract
The current recommendation for therapeutic monitoring of vancomycin has recently suggested AUC-guided dosing in patients with serious methicillin-resistant Staphylococcus aureus infections. The study objective was to evaluate mathematical equations and trapezoidal methods for calculating the 24 h area under the plasma vancomycin concentration-time curve (AUC24). The analysis of plasma vancomycin concentrations was performed in 20 adult patients treated with intravenous vancomycin. For each patient, AUC24 was estimated using two methods including, equation and trapezoidal calculation. The AUC24 from two methods was analyzed for correlation. The correlation between the equation and trapezoidal methods was strong. The coefficient of determination (R2 ) values was greater than .99. The two plasma vancomycin concentrations to achieve the highest correlation were concentration at 2.5 to 3 h after starting the infusion and concentration at 1 h before the next dose. Moreover, the AUC24 calculation from trapezoidal and equation methods showed that 19 out of 20 patients (95%) had AUC24 of more than 400 mg·h/L, and more than 50% in this group had AUC24/MIC greater than 600. Of those patients with AUC-trapezoidal >600, 15.38% of patients had trough under 15 mg/L, 15.38% of patients had trough in the range 15 to 20 mg/L and 69.23% of patients had trough more than 20 mg/L. The results of AUC-equation were similar to those of the AUC-trapezoidal method. Our study confirmed that the AUC monitoring is more appropriate than the trough vancomycin concentration. Given these considerations, the AUC-equation method is better and more practical to use in part of a point-of-care treatment, especially in the part of the Bayesian program is not available. The best sampling time point of the peak concentration was 0.5-1 h after 2-h infusion.
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Affiliation(s)
- Pimonrat Chanapiwat
- Department of Pharmacy, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Taniya Paiboonvong
- Department of Pharmacy Practice, College of PharmacyRangsit UniversityPathum ThaniThailand
| | - Pinyo Rattanaumpawan
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
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36
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Characteristics and calculations of paired vancomycin measurements for determination of 24-h area-under-curve (AUC). Pract Lab Med 2023; 34:e00310. [PMID: 36798591 PMCID: PMC9926295 DOI: 10.1016/j.plabm.2023.e00310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/12/2023] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
Background Current pharmacy practice guidelines recommend 24-h area-under-curve (AUC24) targets for use of vancomycin against methicillin-resistant Staphylococcus aureus (MRSA). AUC protocol-specific vancomycin orders were begun recently (2022) at our institution. We reviewed initial AUC protocol-associated data and calculations. Methods AUC24 calculations are derived from timed, paired measurements of vancomycin (V1,V2). We retrieved paired (V1,V2) measurements for a 90-day interval. Calculations to obtain AUC24 were performed according to two accepted methods (A, B) that assume first-order kinetics for vancomycin elimination between V1 and V2. Results 44 (V1,V2) measurement pairs were from among 27 patients. Dosing intervals were 8, 12, or 24 h. The first-order rate constant k was normally distributed (k = 0.096 ± 0.046 1/h); t1/2 ranged from 3 to 30 h. For target AUC24 = 400-600 h × μg/mL, 55% of calculated AUC24 results were within target. Imprecision for calculated k was predicted to be least when V2 is a trough level. Method B results were greater than Method A results by a factor of 1.07. Conclusions 45% of AUC24 results indicated need for change in dosage. Recommendations are that average results from A and B methods of calculation should be used, and that V1 and V2 should be as widely separated as possible.
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The Bayesian-Based Area under the Curve of Vancomycin by Using a Single Trough Level: An Evaluation of Accuracy and Discordance at Tertiary Care Hospital in KSA. Healthcare (Basel) 2023; 11:healthcare11030362. [PMID: 36766937 PMCID: PMC9914540 DOI: 10.3390/healthcare11030362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/01/2023] Open
Abstract
The AUC0-24 is the most accurate way to track the vancomycin level while the Cmin is not an accurate surrogate. Most hospitals in Saudi Arabia are under-practicing the AUC-guided vancomycin dosing and monitoring. No previous work has been conducted to evaluate such practice in the whole kingdom. The current study objective is to calculate the AUC0-24 using the Bayesian dosing software (PrecisePK), identify the probability of patients who receive the optimum dose of vancomycin, and evaluate the accuracy and precision of the Bayesian platform. This retrospective study was conducted at King Abdulaziz medical city, Jeddah. All adult patients treated with vancomycin were included. Pediatric patients, critically ill patients requiring ICU admission, patients with acute renal failure or undergoing dialysis, and febrile neutropenic patients were excluded. The AUC0-24 was predicted using the PrecisePK platform based on the Bayesian principle. The two-compartmental model by Rodvold et al. in this platform and patients' dose data were utilized to calculate the AUC0-24 and trough level. Among 342 patients included in the present study, the mean of the estimated vancomycin AUC0-24 by the posterior model of PrecisePK was 573 ± 199.6 mg, and the model had a bias of 16.8%, whereas the precision was 2.85 mg/L. The target AUC0-24 (400 to 600 mg·h/L) and measured trough (10 to 20 mg/L) were documented in 127 (37.1%) and 185 (54%), respectively. Furthermore, the result demonstrated an increase in odds of AUC0-24 > 600 mg·h/L among trough level 15-20 mg/L group (OR = 13.2, p < 0.05) as compared with trough level 10-14.9 mg/L group. In conclusion, the discordance in the AUC0-24 ratio and measured trough concentration may jeopardize patient safety, and implantation of the Bayesian approach as a workable alternative to the traditional trough method should be considered.
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Shi Y, Alexander BT, Avedissian S, Bergman SJ, Cortés-Penfield N. In Outpatients Receiving Parenteral Vancomycin, Dosing Adjustments Produced by Area Under the Curve-Based and Trough-Based Monitoring Differ Only at the Extremes of the Therapeutic Trough Range. Open Forum Infect Dis 2023; 10:ofac696. [PMID: 36751644 PMCID: PMC9898881 DOI: 10.1093/ofid/ofac696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Area under the curve (AUC)-based vancomycin dosing reduces nephrotoxicity but is burdensome. Reviewing 115 adults receiving ≥2 weeks of outpatient vancomycin, we found AUC-based and trough-based dose adjustments discordant only for troughs <12 or >16 mg/L. Selective versus universal outpatient AUC calculation would likely offer similar benefit with reduced workload.
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Affiliation(s)
- Yufei Shi
- University of Nebraska Medical Center, College of Pharmacy, Omaha, Nebraska, USA
| | | | - Sean Avedissian
- University of Nebraska Medical Center, College of Pharmacy, Omaha, Nebraska, USA,Antiviral Pharmacology Laboratory, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Scott J Bergman
- University of Nebraska Medical Center, College of Pharmacy, Omaha, Nebraska, USA,Department of Pharmacy, Nebraska Medicine, Omaha, Nebraska, USA
| | - Nicolás Cortés-Penfield
- Correspondence: Nicolás Cortés-Penfield, MD, Division of Infectious Diseases, University of Nebraska Medical Center, 985400 Nebraska Medical Center, MSB 5581, Omaha, NE 68198 (). Bryan Alexander, Nebraska Medicine, 98500 Nebraska Medical Center, Omaha, NE 68198 ()
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Isavuconazole Pharmacokinetics and Pharmacodynamics in Children. Pharmaceutics 2022; 15:pharmaceutics15010075. [PMID: 36678704 PMCID: PMC9865364 DOI: 10.3390/pharmaceutics15010075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022] Open
Abstract
Isavuconazole is a broad-spectrum azole anti-fungal not yet approved in children. We conducted a retrospective, single-center review of isavuconazole use and routine therapeutic drug monitoring in pediatric patients, extracting demographic, dosing, concentration, mortality and hepatoxicity data. We constructed a nonparametric population model using Pmetrics. Of 26 patients, 19 (73%) were male. The mean (SD) age and weight were 12.7 (5.5) years and 50.9 (26.8) kg. Eighty percent received between 9.7 and 10.6 mg/kg per dose. Ten (38%) subjects had proven fungal disease and eight (31%) had probable disease, mostly with Candida and Aspergillus spp. The predicted steady-state isavuconazole concentrations in our patients were similar to previous reports in children and adults, and simulations with the proposed dosing of 10 mg/kg/dose every 8 h for 2 days followed by once daily maintenance matched effective adult exposures. Attributable mortality (5 of 11 deaths) was associated with steady-state daily AUC < 60 mg∗h/L and higher AST/ALT with trough concentrations > 5 mg/L. Neither dose nor trough alone correlated well with AUC, but AUC can be estimated with one sample 10 h after the first maintenance dose or a trough concentration, if combined with a Bayesian approach or a peak and trough without a Bayesian approach.
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Ondrush NM, Ademovic R, Seabury RW, Darko W, Miller CD, Mogle BT. Comparison of vancomycin area under the concentration-time curve (AUC) using two-point pharmacokinetics versus two open-access online single-concentration vancomycin calculators. J Clin Pharm Ther 2022; 47:2223-2229. [PMID: 36351763 DOI: 10.1111/jcpt.13795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/16/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Current vancomycin monitoring guidelines recommend the use of area under the concentration-time curve (AUC24 ) monitoring in patients with serious Methicillin-Resistant Staphylococcus aureus (MRSA) infections by utilizing either a Bayesian approach or first-order analytic equations. Several open-access websites exist that allow estimation of vancomycin AUC24 with the use of a single steady-state concentration. It is uncertain how these open-access calculators perform against guideline-recommended methods. The objective was to compare AUC24 estimates from two online, open-access, single-concentration vancomycin calculators compared with the two-point pharmacokinetic (2PK) method. METHODS AUC24 estimates were made using the 2PK reference method and the single-concentration vancomycin calculators, ClinCalc and VancoPK. The AUC24 estimates from the 2PK reference method were compared to the online calculators by assessing bias (median AUC24 difference) and precision (AUC24 difference ± 100 mg*h/L). Clinical precision was also assessed by characterizing the frequency that the 2PK reference method and the online calculators showed clinical disagreement based on the following AUC24 categories: (1) AUC24 < 400 mg*h/L; (2) AUC24 400-600 mg*h/L and (3) AUC24 > 600 mg*h/L. RESULTS AND DISCUSSION A total of 253 patients were included in the study. The AUC24 estimates from the ClinCalc and VancoPK single-concentration vancomycin calculators showed some bias and imprecision, though VancoPK appeared to have less. Clinical disagreement versus the 2PK reference method occurred in 31.2% and 19.4% of AUC24 estimates from the ClinCalc and VancoPK single-concentration vancomycin calculators, suggesting clinical imprecision. WHAT IS NEW AND CONCLUSION The AUC24 estimates from single-concentration, online vancomycin calculators showed some bias and imprecision in comparison to the 2PK method. Institutions should validate these online, trough-only calculators relative to a 2PK method in their patient populations prior to adoption as standard-of-care.
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Affiliation(s)
- Nicole M Ondrush
- The Mount Sinai Hospital, One Gustave L. Levy Place, New York, USA
| | - Rejs Ademovic
- Upstate University Hospital, Syracuse, New York, USA
| | | | - William Darko
- Upstate University Hospital, Syracuse, New York, USA
| | | | - Bryan T Mogle
- Upstate University Hospital, Syracuse, New York, USA
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Aljutayli A, Thirion DJ, Nekka F. Critical assessment of the revised guidelines for vancomycin therapeutic drug monitoring. Biomed Pharmacother 2022; 155:113777. [DOI: 10.1016/j.biopha.2022.113777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/02/2022] Open
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Yang J, Liu S, Lu J, Sun T, Wang P, Zhang X. An area under the concentration-time curve threshold as a predictor of efficacy and nephrotoxicity for individualizing polymyxin B dosing in patients with carbapenem-resistant gram-negative bacteria. Crit Care 2022; 26:320. [PMID: 36258197 PMCID: PMC9578216 DOI: 10.1186/s13054-022-04195-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Evidence supports therapeutic drug monitoring of polymyxin B, but clinical data for establishing an area under the concentration-time curve across 24 h at steady state (AUCss,24 h) threshold are still limited. This study aimed to examine exposure-response/toxicity relationship for polymyxin B to establish an AUCss,24 h threshold in a real-world cohort of patients. METHODS Using a validated Bayesian approach to estimate AUCss,24 h from two samples, AUCss,24 h threshold that impacted the risk of polymyxin B-related nephrotoxicity and clinical response were derived by classification and regression tree (CART) analysis and validated by Cox regression analysis and logical regression analysis. RESULTS A total of 393 patients were included; acute kidney injury (AKI) was 29.0%, clinical response was 63.4%, and 30-day all-cause mortality was 35.4%. AUCss,24 h thresholds for AKI of > 99.4 mg h/L and clinical response of > 45.7 mg h/L were derived by CART analysis. Cox and logical regression analyses showed that AUCss,24 h of > 100 mg h/L was a significant predictor of AKI (HR 16.29, 95% CI 8.16-30.25, P < 0.001) and AUCss,24 h of ≥ 50 mg h/L (OR 4.39, 95% CI 2.56-7.47, P < 0.001) was independently associated with clinical response. However, these exposures were not associated with mortality. In addition, the correlation between trough concentration (1.2-2.8 mg/L) with outcomes was similar to AUCss,24 h. CONCLUSIONS For critically ill patients, AUCss,24 h threshold of 50-100 mg h/L was associated with decreased nephrotoxicity while assuring clinical efficacy. Therapeutic drug monitoring is recommended for individualizing polymyxin B dosing.
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Affiliation(s)
- Jing Yang
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Shaohua Liu
- grid.412633.10000 0004 1799 0733Department of General Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Jingli Lu
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Tongwen Sun
- grid.412633.10000 0004 1799 0733Department of General Intensive Care Unit, First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Peile Wang
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Xiaojian Zhang
- grid.412633.10000 0004 1799 0733Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe East Road, Zhengzhou, Henan 45005 People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Key Laboratory of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China ,grid.207374.50000 0001 2189 3846Henan Engineering Research Center for Application and Translation of Precision Clinical Pharmacy, Zhengzhou University, Zhengzhou, People’s Republic of China
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Chen L, Li C, Bai H, Li L, Chen W. Use of modeling and simulation to predict the influence of triazole antifungal agents on the pharmacokinetics of zanubrutinib and acalabrutinib. Front Pharmacol 2022; 13:960186. [PMID: 36299883 PMCID: PMC9588929 DOI: 10.3389/fphar.2022.960186] [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: 06/02/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Bruton’s tyrosine kinase (BTK) inhibitors are commonly used in the targeted therapy of B-cell malignancies. It is reported that myelosuppression and fungal infections might occur during antitumor therapy of BTK inhibitors, therefore a combination therapy with triazole antifungals is usually required. Objective: To evaluate the influence of different triazoles (voriconazole, fluconazole, itraconazole) on the pharmacokinetics of BTK inhibitors (zanubrutinib, acalabrutinib) and to quantify the drug-drug interactions (DDIs) between them. Methods: The physiologically-based pharmacokinetic (PBPK) models were developed based on pharmacokinetic parameters and physicochemical data using Simcyp® software. These models were validated using clinically observed plasma concentrations data which based on existing published studies. The successfully validated PBPK models were used to evaluate and predict potential DDIs between BTK inhibitors and different triazoles. BTK inhibitors and triazole antifungal agents were simulated by oral administration. Results: Simulated plasma concentration-time profiles of the zanubrutinib, acalabrutinib, voriconazole, fluconazole, and itraconazole are consistent with the clinically observed profiles which based on existing published studies, respectively. The exposures of BTK inhibitors increase by varying degrees when co-administered with different triazole antifungals. At multiple doses regimen, voriconazole, fluconazole and itraconazole may increase the area under plasma concentration-time curve (AUC) of zanubrutinib by 127%, 81%, and 48%, respectively, and may increase the AUC of acalabrutinib by 326%, 119%, and 264%, respectively. Conclusion: The PBPK models sufficiently characterized the pharmacokinetics of BTK inhibitors and triazole antifungals, and were used to predict untested clinical scenarios. Voriconazole exhibited the greatest influence on the exposures of BTK inhibitors. The dosage of zanubrutinib or acalabrutinib need to be reduced when co-administered with moderate CYP3A inhibitors.
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Affiliation(s)
- Lu Chen
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Chao Li
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Hao Bai
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Lixian Li
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
| | - Wanyi Chen
- Department of Pharmacy, Chongqing University Cancer Hospital, Chongqing, China
- Chongqing University, Chongqing, China
- *Correspondence: Wanyi Chen,
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Vancomycin Area under the Concentration-Time Curve Estimation Using Bayesian Modeling versus First-Order Pharmacokinetic Equations: A Quasi-Experimental Study. Antibiotics (Basel) 2022; 11:antibiotics11091239. [PMID: 36140021 PMCID: PMC9495010 DOI: 10.3390/antibiotics11091239] [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: 08/29/2022] [Revised: 09/10/2022] [Accepted: 09/12/2022] [Indexed: 11/22/2022] Open
Abstract
Aim: To evaluate the efficiency of Bayesian modeling software and first-order pharmacokinetic (PK) equations to calculate vancomycin area under the concentration-time curve (AUC) estimations. Methods: Unblinded, crossover, quasi-experimental study at a tertiary care hospital for patients receiving intravenous vancomycin. Vancomycin AUC monitoring was compared using Bayesian modeling software or first-order PK equations. The primary endpoint was the time taken to estimate the AUC and determine regimen adjustments. Secondary endpoints included the percentage of vancomycin concentrations usable for AUC calculations and acute kidney injury (AKI). Results: Of the 124 patients screened, 34 patients had usable vancomycin concentrations that led to 44 AUC estimations. Without electronic health record (EHR) integration, the time from assessment to intervention in the Bayesian modeling platform was a median of 9.3 min (quartiles Q1–Q3 7.8–12.4) compared to 6.8 min (Q1–Q3 4.8–8.0) in the PK equations group (p = 0.004). With simulated Bayesian software integration into the EHR, however, the median time was 3.8 min (Q1–Q3 2.3–6.9, p = 0.019). Vancomycin concentrations were usable in 88.2% in the Bayesian group compared to 48.3% in the PK equation group and there were no cases of AKI. Conclusion: Without EHR integration, Bayesian software was more time-consuming to assess vancomycin dosing than PK equations. With simulated integration, however, Bayesian software was more time efficient. In addition, vancomycin concentrations were more likely to be usable for calculations in the Bayesian group.
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45
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Morales Junior R, Tiguman GMB, D'Amaro Juodinis V, Santos ICPDF, Leite FS, Vercelino JG, de Lima BD, Barbosa LMG. Trough-Guided Versus AUC/MIC-Guided Vancomycin Monitoring: A Cost Analysis. Clin Ther 2022; 44:e91-e96. [PMID: 36031477 DOI: 10.1016/j.clinthera.2022.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/06/2022] [Accepted: 07/28/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Recent vancomycin dosing and monitoring guidelines recommend monitoring vancomycin area under the 24-hour time-concentration curve instead of traditional trough-only monitoring. This study aimed to compare the total costs of vancomycin dosing and monitoring between trough-guided and AUC-guided approaches in a quaternary hospital from Brazil. METHODS In this retrospective cohort study, patients were divided into 2 groups according to the monitoring method. Patients with previous renal impairment were excluded. Vancomycin AUC was estimated by using 2 steady-state serum concentrations and first-order kinetics equations. The primary outcome was total cost of vancomycin therapy and monitoring from the hospital perspective, which included costs of cumulative doses, laboratory fees, materials used in blood collection, nursing time for collection, and pharmacist time for result interpretation. FINDINGS A total of 68 patients were included in the AUC/MIC-guided monitoring group, and 76 patients were included in the trough-guided monitoring group. There were no significant differences between groups regarding baseline serum creatinine level, duration of vancomycin therapy, and cumulative vancomycin dose. The median (interquartile range) total vancomycin drug and monitoring cost was $298.32 ($153.81-$429.85) for the AUC/MIC-guided group compared with $285.59 ($198.81-$435.57) for the trough-guided group (P = 0.9658). IMPLICATIONS Vancomycin AUC estimation using 2 steady-state serum concentrations and first-order kinetics equations is a feasible alternative for limited-resource institutions that intend to transition from a trough approach to AUC/MIC-guided monitoring. (Clin Ther. 2022;44:XXX-XXX) © 2022 Elsevier HS Journals, Inc.
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Affiliation(s)
- Ronaldo Morales Junior
- Department of Clinical Pharmacy, Sírio-Libanês Hospital, São Paulo, Brazil; School of Pharmaceutical Sciences, São Paulo University, São Paulo, Brazil.
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Karas C, Manning K, Childress DT, Covington EW, Manis MM. Evaluating the Safety of Trough Versus Area Under the Curve (AUC)-Based Dosing Method of Vancomycin With Concomitant Piperacillin-Tazobactam. J Pharm Technol 2022; 38:218-224. [PMID: 35832564 PMCID: PMC9272489 DOI: 10.1177/87551225221101736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
Background: Vancomycin and piperacillin-tazobactam (VPT) is a common antibiotic combination used in hospitals, and there has been increasing data indicating that the combination is associated with increased rates of acute kidney injury (AKI). It is unclear if the dosing method of vancomycin would mitigate the risk of AKI seen with VPT. Objective: To observe and compare incidence of AKI in patients on VPT when using the trough-based dosing method versus the area-under-the-curve (AUC)-based dosing method. Methods: This was a multi-center, retrospective, observational study at 3 community hospitals. Adults receiving at least 48 hours of VPT were included. Patients with severe renal dysfunction, pregnant patients, prisoners, and patients with central nervous system infections, or malignancy were excluded. The primary outcome was incidence of AKI as defined by the Infectious Disease Society of America (IDSA) criteria. Results: A total of 300 patients were included in the study; 150 patients in both the trough and AUC groups. A total of 23 patients (15%) in the trough group and 17 patients (11%) in the AUC group met the primary outcome (odds ratio [OR]: 0.7058, 95% confidence interval [CI]: [0.3603, 1.3826], P = .3098). Conclusion and Relevance: The incidence of AKI was lower in the AUC group compared with the trough group; however, this was not significant. The results of our study suggest that there is no difference between incidence of AKI when using trough- or AUC-based dosing in those receiving VPT. Because of the small sample size and retrospective nature of the study, more data are needed.
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Affiliation(s)
| | | | | | | | - Melanie M. Manis
- McWhorter School of Pharmacy, Samford
University, Birmingham, AL, USA
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47
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Gu Q, Jones N, Drennan P, Peto TE, Walker AS, Eyre DW. Assessment of an institutional guideline for vancomycin dosing and identification of predictive factors associated with dose and drug trough levels. J Infect 2022; 85:382-389. [PMID: 35840011 DOI: 10.1016/j.jinf.2022.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/16/2022] [Accepted: 06/28/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of an antimicrobial guideline for vancomycin prescribing deployed using electronic prescribing aid and web/phone-based app. To define factors associated with guideline compliance and drug levels, and to investigate if antimicrobial dosing recommendations can be refined using routinely collected electronic healthcare record data. METHODS We used data from Oxford University Hospitals between 01-January-2016 and 01-June-2021 and multivariable regression models to investigate factors associated with dosing compliance, drug levels and acute kidney injury (AKI). RESULTS 3767 patients received intravenous vancomycin for ≥24 h. Compliance with recommended loading and initial maintenance doses reached 84% and 70% respectively; 72% of subsequent maintenance doses were correctly adjusted. However, only 26% first and 32% subsequent levels reached the target range, and for patients with ongoing vancomycin treatment, 55-63% achieved target levels at 5 days. Drug levels were independently higher in older patients. Incidence of AKI was low (5.7%). Model estimates were used to propose updated age, weight and eGFR specific guidelines. CONCLUSION Despite good compliance with guidelines for vancomycin dosing, the proportion of drug levels achieving the target range remained suboptimal. Routinely collected electronic data can be used at scale to inform pharmacokinetic studies and could improve vancomycin dosing.
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Affiliation(s)
- Qingze Gu
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Philip Drennan
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Tim Ea Peto
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom
| | - David W Eyre
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, United Kingdom.
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Sonoda A, Iwashita Y, Takada Y, Hamazono R, Ishida K, Imamura H. Prediction Accuracy of Area under the Concentration-Time Curve of Vancomycin by Bayesian Approach Using Creatinine-Based Equations of Estimated Kidney Function in Bedridden Elderly Japanese Patients. Biol Pharm Bull 2022; 45:763-769. [PMID: 35370223 DOI: 10.1248/bpb.b22-00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
An administration plan for vancomycin (VCM) in bedridden elderly patients has not been established. This retrospective study aimed to evaluate the prediction accuracy of the area under the concentration-time curve (AUC) of VCM by the Bayesian approach using creatinine-based equations of estimated kidney function in such patients. Kidney function was estimated using the Japanese equation of estimated glomerular filtration rate (eGFR) and the Cockcroft-Gault equation of estimated creatinine clearance (eCCr). eCCr (serum creatinine (SCr) + 0.2) was calculated by substituting the SCr level +0.2 mg/dL into the Cockcroft-Gault equation. For eGFR/0.789, eGFR, eCCr, and eCCr (SCr + 0.2), the AUC values were calculated by the Bayesian approach using the therapeutic drug monitoring (TDM) software, BMs-Pod (ver 8.06) and denoted as AUCeGFR/0.789, AUCeGFR, AUCeCCr, and AUCeCCr (SCr + 0.2) respectively. The reference AUC (AUCREF) was calculated by applying VCM's peak and trough steady-state concentrations to first-order pharmacokinetic equations. The medians (range) of AUCeGFR/0.789/AUCREF, AUCeGFR/AUCREF, AUCeCCr/AUCREF, and AUCeCCr (SCr + 0.2)/AUCREF were 0.88 (0.74-0.93), 0.90 (0.79-1.04), 0.92 (0.81-1.07), and 1.00 (0.88-1.11), respectively. Moreover, the percentage of patients within 10% of the AUCREF, defined as |Bayesian-estimated AUC - AUCREF| < AUCREF × 0.1, was the highest (86%) in AUCeCCr (SCr + 0.2). These results suggest that the Bayesian approach using eCCr (SCr + 0.2) has the highest prediction accuracy for the AUCREF in bedridden elderly patients. Although further studies are required with more accurate determination methods of the CCr and AUC, our findings highlight the potential of eCCr (SCr + 0.2) for estimating VCM's AUC by the Bayesian approach in such patients.
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Affiliation(s)
| | | | - Yukina Takada
- Department of Pharmacy, Izumi Regional Medical Center
| | - Ryu Hamazono
- Department of Pharmacy, Izumi Regional Medical Center
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Uster DW, Wicha SG. Optimized sampling to estimate vancomycin drug exposure: Comparison of pharmacometric and equation-based approaches in a simulation-estimation study. CPT Pharmacometrics Syst Pharmacol 2022; 11:711-720. [PMID: 35259285 PMCID: PMC9197536 DOI: 10.1002/psp4.12782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/31/2022] Open
Abstract
Vancomycin dosing should be accompanied by area under the concentration‐time curve (AUC)–guided dosing using model‐informed precision dosing software according to the latest guidelines. Although a peak plus a trough sample is considered the gold standard to determine the AUC, single‐sample strategies might be more economic. Yet, optimal sampling times for AUC determination of vancomycin have not been systematically evaluated. In the present study, automated one‐ or two‐sample strategies were systematically explored to estimate the AUC with a model averaging and a model selection algorithm. Both were compared with a conventional equation‐based approach in a simulation‐estimation study mimicking a heterogenous patient population (n = 6000). The optimal single‐sample timepoints were identified between 2–6.5 h post dose, with varying bias values between −2.9% and 1.0% and an imprecision of 23.3%–24.0% across the population pharmacokinetic approaches. Adding a second sample between 4.5–6.0 h improved the predictive performance (−1.7% to 0.0% bias, 17.6%–18.6% imprecision), although the difference in the two‐sampling strategies were minor. The equation‐based approach was always positively biased and hence inferior to the population pharmacokinetic approaches. In conclusion, the approaches always preferred samples to be drawn early in the profile (<6.5 h), whereas sampling of trough concentrations resulted in a higher imprecision. Furthermore, optimal sampling during the early treatment phase could already give sufficient time to individualize the second dose, which is likely unfeasible using trough sampling.
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Affiliation(s)
- David W Uster
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
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Chang J, Patel D, Vega A, Claeys KC, Heil EL, Scheetz MH. Does calculation method matter for targeting vancomycin area under the curve? J Antimicrob Chemother 2022; 77:2245-2250. [PMID: 35640658 PMCID: PMC9890897 DOI: 10.1093/jac/dkac151] [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: 11/16/2021] [Accepted: 04/13/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To assess differences in vancomycin AUC estimates from two common, clinically applied first-order pharmacokinetic equation methods compared with Bayesian estimates. METHODS A cohort of patients who received vancomycin and therapeutic drug monitoring was studied. First-order population pharmacokinetic equations were used to guide initial empirical dosing. After receipt of the first dose, patients had peak and trough serum levels drawn and steady-state AUC was estimated using first-order pharmacokinetic equations as standard care. We subsequently created a Bayesian model and used individual Empirical Bayes Estimates to precisely calculate vancomycin AUC24-48, AUC48-72 and AUC72-96 in this cohort. AUC at steady state (AUCSS) differences from the first-order methods were compared numerically and categorically (i.e. below, within or above 400-600 mg·h/L) to Bayesian AUCs, which served as the gold standard. RESULTS A total of 65 adult inpatients with 409 plasma samples were included in this analysis. A two-compartment intravenous infusion model with first-order elimination fit the data well. The mean of Bayesian AUC24-48 was not significantly different from AUC estimates from the two first-order pharmacokinetic equation methods (P = 0.68); however, Bayesian AUC48-72 and Bayesian AUC72-96 were both significantly different when compared with both first-order pharmacokinetic equation methods (P < 0.01 for each). At the patient level, categorical classifications of AUC estimates from the two first-order pharmacokinetic equation methods differed from categorizations derived from the Bayesian calculations. Categorical agreement was ∼50% between first-order and Bayesian calculations, with declining categorical agreement observed with longer treatment courses. Differences in categorical agreement between calculation methods could potentially result in different dose recommendations for the patient. CONCLUSIONS Bayesian-calculated AUCs between 48-72 and 72-96 h intervals were significantly different from first-order pharmacokinetic method-estimated AUCs at steady state. The various calculation methods resulted in different categorical classification, which could potentially lead to erroneous dosing adjustments in approximately half of the patients.
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Affiliation(s)
- Jack Chang
- Midwestern University College of Pharmacy, Department of Pharmacy Practice, Downers Grove, IL, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
| | - Dhara Patel
- Midwestern University College of Pharmacy, Department of Pharmacy Practice, Downers Grove, IL, USA
| | - Ana Vega
- Jackson Memorial Hospital, Department of Pharmacy, Miami, FL, USA
| | - Kimberly C Claeys
- University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD, USA
| | - Emily L Heil
- University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD, USA
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