Novel LC–MS/MS method for plasma vancomycin: Comparison with immunoassays and clinical impact

Dose Individualisation of Antimicrobials from a Pharmacometric Standpoint: The Current Landscape

Successful antimicrobial therapy depends on achieving optimal drug concentrations within individual patients. Inter-patient variability in pharmacokinetics (PK) and differences in pathogen susceptibility (reflected in the minimum inhibitory concentration, [MIC]) necessitate personalised approaches. Dose individualisation strategies aim to address this challenge, improving treatment outcomes and minimising the risk of toxicity and antimicrobial resistance. Therapeutic drug monitoring (TDM), with the application of population pharmacokinetic (popPK) models, enables model-informed precision dosing (MIPD). PopPK models mathematically describe drug behaviour across populations and can be combined with patient-specific TDM data to optimise dosing regimens. The integration of machine learning (ML) techniques promises to further enhance dose individualisation by identifying complex patterns within extensive datasets. Implementing these approaches involves challenges, including rigorous model selection and validation to ensure suitability for target populations. Understanding the relationship between drug exposure and clinical outcomes is crucial, as is striking a balance between model complexity and clinical usability. Additionally, regulatory compliance, outcome measurement, and practical considerations for software implementation will be addressed. Emerging technologies, such as real-time biosensors, hold the potential for revolutionising TDM by enabling continuous monitoring, immediate and frequent dose adjustments, and near patient testing. The ongoing integration of TDM, advanced modelling techniques, and ML within the evolving digital health care landscape offers a potential for enhancing antimicrobial therapy. Careful attention to model development, validation, and ethical considerations of the applied techniques is paramount for successfully optimising antimicrobial treatment for the individual patient.

Dose optimization and target attainment of vancomycin in children

Vancomycin is a glycopeptide antibiotic that has been adopted in clinical practice to treat gram-positive infections for more than 70 years. Despite vancomycin's long history of therapeutic use, optimal dose adjustments and pharmacokinetic/pharmacodynamic (PK/PD) target attainment in children are still under debate. Therapeutic drug monitoring (TDM) has been widely integrated into pediatric clinical practice to maximize efficacy and safety of vancomycin treatment. Area under the curve (AUC)-guided TDM has been recently recommended instead of trough-only TDM to ensure PK/PD target attainment of AUC0-24h/minimal inhibitory concentration (MIC) > 400 to 600 and minimize acute kidney injury risk. Bayesian forecasting in pediatric patients allows estimation of population PK to accurately predict individual vancomycin concentrations over time, and consequently total vancomycin exposure. AUC-guided TDM for vancomycin, preferably with Bayesian forecasting, is therefore suggested for all pediatric age groups and special pediatric populations. In this review we aim to analyze the current literature on the pediatric use of vancomycin and summarize the current knowledge on dosing optimization for target attainment in special patient populations.

Therapeutic drug monitoring of glycopeptide antimicrobials: An overview of liquid chromatography-tandem mass spectrometry methods

Therapeutic drug monitoring (TDM) is a critical clinical tool used to optimize the safety and effectiveness of drugs by measuring their concentration in biological fluids. These fluids are primarily plasma or blood. TDM, together with real-time dosage adjustment, contributes highly to the successful management of glycopeptide antimicrobial therapies. Understanding pharmacokinetic/pharmacodynamic (PK/PD) properties is vital for optimizing antimicrobial therapies, as the efficacy of these therapies depends on both the exposure of the patient to the drug (PK) and pharmacodynamic (PD) parameters such as the in vitro estimated minimum drug concentration that inhibits bacterial growth (MIC). Liquid chromatography coupled to tandem mass spectrometry (LC-MS/MS) is widely recognized as the gold standard for measuring small molecules, such as antibiotics. This review provides a comprehensive overview of LC-MS/MS methods available for TDM of glycopeptide antibiotics, including vancomycin, teicoplanin, dalbavancin, oritavancin, and telavancin.

A novel strategy for therapeutic drug monitoring: application of biosensors to quantify antimicrobials in biological matrices

Over the past few years, therapeutic drug monitoring (TDM) has gained practical significance in antimicrobial precision therapy. Yet two categories of mainstream TDM techniques (chromatographic analysis and immunoassays) that are widely adopted nowadays retain certain inherent limitations. The use of biosensors, an innovative strategy for rapid evaluation of antimicrobial concentrations in biological samples, enables the implementation of point-of-care testing (POCT) and continuous monitoring, which may circumvent the constraints of conventional TDM and provide strong technological support for individualized antimicrobial treatment. This comprehensive review summarizes the investigations that have harnessed biosensors to detect antimicrobial drugs in biological matrices, provides insights into the performance and characteristics of each sensing form, and explores the feasibility of translating them into clinical practice. Furthermore, the future trends and obstacles to achieving POCT and continuous monitoring are discussed. More efforts are necessary to address the four key 'appropriateness' challenges to deploy biosensors in clinical practice, paving the way for personalized antimicrobial stewardship.

Rapid Colloidal Gold Immunoassay for Pharmacokinetic Evaluation of Vancomycin in the Cerebrospinal Fluid and Plasma of Beagle Dogs

Vancomycin (VAN), a glycopeptide antibiotic, is the preferred therapeutic agent for treating Gram-positive bacteria. Rapid and precise quantification of VAN levels in cerebrospinal fluid (CSF) and plasma is crucial for optimized drug administration, particularly among elderly patients. Herein, we introduce a novel clinical test strip utilizing colloidal gold competitive immunoassay technology for the expedient detection of VAN. This test strip enables the detection of VAN concentrations in clinical samples such as plasma within 10 min and has a limit of detection of 10.3 ng/mL, with an inhibitory concentration 50% (IC50) value of 44.5 ng/mL. Furthermore, we used the test strip for pharmacokinetic analysis of VAN in the CSF and plasma of beagle dogs. Our results provide valuable insights into the fluctuations of the drug concentration in the CSF and plasma over a 24 h period after a single intravenous dose of 12 mg/kg. The test strip results were compared with the results obtained via liquid chromatography-mass spectrometry methods, and the measured VAN concentrations in the CSF and plasma via both of the methods showed excellent agreement.

Simultaneous Quantification of Seven Antifungal Agents in Human Serum Using Liquid Chromatography-Tandem Mass Spectrometry

Systemic antifungal agents are essential for high-risk patients undergoing immunosuppressive therapy or cancer chemotherapy because of the rapid increase in opportunistic fungal infections. Therapeutic drug monitoring is crucial to ensuring the efficacy and safety of antifungal agents owing to their pharmacokinetic variability. In the present study, we developed and validated a quantitative method for the simultaneous detection of seven commonly used antifungal drugs (amphotericin B, isavuconazole, voriconazole, fluconazole, posaconazole, caspofungin, and micafungin) using liquid chromatography-tandem mass spectrometry. Methanol (containing 0.1% formic acid) was used for protein precipitation and only 50 μL of serum was required for the analysis. Chromatographic separation was conducted using a Waters Acquity UPLC C8 column, and one stable isotope-labeled agent and two analogs were used as internal standards. The calibration curves ranged from 0.1 to 50 μg/mL for all agents, and the correlation coefficient (R2) for all calibration curves was above 0.9835. The intra-day precision (1.2-11.2%), inter-day precision (2.4-13.2%), and mean bias values (-10.9 to 13.6%) were within an acceptable range of ±15%. Successful implementation of the developed method in clinical practice would facilitate the effective monitoring of these antifungal agents.

Development and validation of a dried plasma spot LC-MS/MS method for therapeutic monitoring of vancomycin and comparison with enzyme-multiplied immunoassay

Vancomycin is used as an antimicrobial agent for the treatment of severe gram-positive infections. The importance of therapeutic monitoring of antimicrobials has led to the development of more specific sample preparation techniques capable of identifying with accuracy the concentration of this substance in the organism. An aliquot of 10 μl of plasma was transferred to Whatman 903 paper and dried at room temperature. The extraction method was performed by cutting and transferring the paper to a microtube and adding sodium phosphate buffer and internal standard. The mixture was shaken and centrifuged, and a 5-μl aliquot was injected into the analytical system. The optimization of the main parameters that can influence the extraction efficiency was performed using multivariate approaches to obtain the best conditions. The method developed was validated, providing coefficients of determination higher than 0.994 and a lower limit of quantification of 1 mg/L. Within- and between-run precision ranged from 11.4 to 17.30% and from 6.65 to 13.51%, respectively. This method was successfully applied to 75 samples of patients undergoing vancomycin therapy. The method was rapid, simple, and environmentally friendly with satisfactory analytical performance and was advantageous over the laborious and time-consuming methodologies used in therapeutic drug monitoring routine analyses.

An Overview of Analytical Methodologies for Determination of Vancomycin in Human Plasma

Vancomycin is regarded as the last resort of defense for a wide range of infections due to drug resistance and toxicity. The detection of vancomycin in plasma has always aroused particular concern because the performance of the assay affects the clinical treatment outcome. This article reviews various methods for vancomycin detection in human plasma and analyzes the advantages and disadvantages of each technique. Immunoassay has been the first choice for vancomycin concentration monitoring due to its simplicity and practicality, occasionally interfered with by other substances. Chromatographic methods have mainly been used for scientific research due to operational complexity and the particular requirement of the instrument. However, the advantages of a small amount of sample needed, high sensitivity, and specificity makes chromatography irreplaceable. Other methods are less commonly used in clinical applications because of the operational feasibility, clinical application, contamination, etc. Simplicity, good performance, economy, and environmental friendliness have been points of laboratory methodological concern. Unfortunately, no one method has met all of the elements so far.

A novel sensitive analytical method for the simultaneous analysis of vancomycin and teicoplanin in human urine via single high-performance liquid chromatography coupled with photodiode array and mass spectrometry in series

Analysis of vancomycin and teicoplanin in biological fluids is vital since they are used in the treatment of hospital infections. For the determination of both glycopeptides in urine, a sensitive and accurate analytical method using high‐performance liquid chromatography coupled with photodiode array and mass spectrometry was developed and validated. This research work is the first attempt to develop a chromatographic method for the determination of two glycopeptides with structural similarities. Moreover, the used non‐invasive sampling method is an advantage of this research effort, especially when the blood sampling is difficult. Urine was treated with acetonitrile and 5% trichloroacetic acid, followed by solid‐phase extraction. The chromatographic separation was established at a C18 column (4.6 × 150 mm, 5 μm), using a gradient method and an electrospray ionization source in a positive mode. The linearity of the method was R²≥ 0.9900. The precision was estimated with a maximum coefficient of variation below 15%, while the accuracy ranged from 64 to 121%. The limit of detection and quantification of both glycopeptides ranged from 0.076 up to 0.33 mg/L and 0.33 up to 2.1 mg/L, respectively, showing the same sensitivity as the triple quadrupole mass spectrometry, which is the most frequently used method.

Transdermal Delivery of High Molecular Weight Antibiotics to Deep Tissue Infections via Droplette Micromist Technology Device (DMTD)

Wound infection by multidrug-resistant (MDR) bacteria is a major disease burden. Systemic administration of broad-spectrum antibiotics colistin methanesulfonate (CMS) and vancomycin are the last lines of defense against deep wound infections by MDR bacteria. However, systemic administration of CMS and vancomycin are linked to life-threatening vital organ damage. Currently there are no effective topical application strategies to deliver these high molecular weight antibiotics across the stratum corneum. To overcome this difficulty, we tested if high molecular weight antibiotics delivered by Droplette micromist technology device (DMTD), a transdermal delivery device that generates a micromist capable of packaging large molecules, could attenuate deep skin tissue infections. Using green fluorescent protein-tagged E. coli and live tissue imaging, we show that (1) the extent of attenuation of deep-skin E. coli infection was similar when treated with topical DMTD- or systemic IP (intraperitoneal)-delivered CMS; (2) DMTD-delivered micromist did not spread the infection deeper; (3) topical DMTD delivery and IP delivery resulted in similar levels of vancomycin in the skin after a 2 h washout period; and (4) IP-delivered vancomycin was about 1000-fold higher in kidney and plasma than DMTD-delivered vancomycin indicating systemic toxicity. Thus, topical DMTD delivery of these antibiotics is a safe treatment for the difficult-to-treat deep skin tissue infections by MDR bacteria.

Development, validation, and application of an UPLC-MS/MS method for vancomycin, norvancomycin, methotrexate, paclitaxel, and imatinib analysis in human plasma

Background

Vancomycin, norvancomycin, methotrexate, paclitaxel, and imatinib are five commonly used drugs which are all recommended to therapeutic drug monitoring in clinical settings. However, the blood concentration monitoring of these drugs and the interpretations of the test results are limited to some extent due to the differences of testing instruments and testing methods.

Methods

We established an ultra-performance liquid chromatography with tandem mass spectrometry (UPLC-MS/MS) method for simultaneous quantification of vancomycin, norvancomycin, methotrexate, paclitaxel, and imatinib in human plasma. The method was validated according to the guideline for bioanalytical method validation and applied in clinical therapy.

Results

The calibration ranges of vancomycin, norvancomycin, methotrexate, paclitaxel, and imatinib were 0.5–100 μg/mL, 0.5–100 μg/mL, 5–1000 ng/mL, 10–2000 ng/mL, and 5–500 ng/mL, respectively. Inaccuracy and imprecision of every drug were less than 15%. The internal standard normalized recovery rates of vancomycin and norvancomycin were about 45%, while which of methotrexate, paclitaxel, and imatinib were almost 100%. No obvious carryover effect was observed. Samples were stable for at least 24 h in the automatic sampler, 72 h at 4°C, and 1 week in −80°C. There were no differences of concentrations between plasma and serum for the five drugs. Moreover, there were positive correlations between methotrexate and vancomycin concentrations and creatinine, as well as positive correlation between imatinib concentration and age of the patient.

Conclusions

The UPLC-MS/MS method was competent for the simultaneous monitoring of vancomycin, norvancomycin, methotrexate, paclitaxel, and imatinib because of its short analysis time, high specificity, and accuracy.

Optimal Practice for Vancomycin Therapeutic Drug Monitoring: Position Statement From the Anti-infectives Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology

ABSTRACT

Individualization of vancomycin dosing based on therapeutic drug monitoring (TDM) data is known to improve patient outcomes compared with fixed or empirical dosing strategies. There is increasing evidence to support area-under-the-curve (AUC24)-guided TDM to inform vancomycin dosing decisions for patients receiving therapy for more than 48 hours. It is acknowledged that there may be institutional barriers to the implementation of AUC24-guided dosing, and additional effort is required to enable the transition from trough-based to AUC24-based strategies. Adequate documentation of sampling, correct storage and transport, accurate laboratory analysis, and pertinent data reporting are required to ensure appropriate interpretation of TDM data to guide vancomycin dosing recommendations. Ultimately, TDM data in the clinical context of the patient and their response to treatment should guide vancomycin therapy. Endorsed by the International Association of Therapeutic Drug Monitoring and Clinical Toxicology, the IATDMCT Anti-Infectives Committee, provides recommendations with respect to best clinical practice for vancomycin TDM.

Degradation of vancomycin in external quality assessment samples is a factor to underestimate its concentration

Aim: To compare the difference between the measured and target values in vancomycin external quality assessment (EQA) samples and to investigate the factors for underestimating its concentration. Materials & methods: A retrospective analysis of 195 international vancomycin EQA results was performed. Deviations of the concentrations determined by TDx fluorescence polarization immunoassay (FPIA), Axsym FPIA and Architect chemiluminescence microparticle immunoassay (CMIA) method were -2.43, -16.28 and -10.53%, respectively. Chromatographic peaks of the crystalling degradation products appeared in samples with large deviations. Vancomycin were degraded after long-term transporting and high temperature. Conclusion: Vancomycin concentrations measured by Axsym FPIA and Architect CMIA methods were likely to be underestimated. Long-term transporting resulted in low EQA results, suggesting that establishing a local EQA system for vancomycin is essential.

Nitroxyl Radical/Copper-Catalyzed Electrooxidation of Alcohols and Amines at Low Potentials

Nitroxyl radicals, such as 2,2,6,6-tetramethylpiperidine N-oxyl (TEMPO), can catalyze the electrochemical oxidation of alcohols and amines. Because the oxidation current obtained in this process depends on the concentration of alcohols and amines, this process can be applied to their sensing. However, the relatively high oxidation potentials required by nitroxyl radicals can induce interfering oxidation currents from various reductive substances in biological samples, which affects the accuracy of analyte measurements. In this study, we examined the electrooxidation of alcohols and amines at a low potential by applying cooperative oxidation catalysis using a nitroxyl radical and a copper salt. Nortropine N-oxyl (NNO), which showed higher catalytic activity than TEMPO was used as the nitroxyl radical. An increase in the oxidation current was observed at the low potential, and this increase depended on the alcohol concentration. In the case of the electrooxidation of amines, a positive correlation between oxidation current and amine concentration was observed at low amine concentrations. Therefore, low-potential cooperative catalysis can be applied to alcohol and amine electrooxidation for the development of accurate sensors suitable for clinical settings.

Catalysis of electro-oxidation of antibiotics by nitroxyl radicals and the electrochemical sensing of vancomycin

Quantifying drug concentrations in vivo quickly and easily is possible using electrochemical methods. The present study describes the electrochemical detection of vancomycin (VCM) and other antibiotics from the current obtained using nitroxyl radicals as electrocatalysts. Nortropine N-oxyl (NNO), which is more active than 2,2,6,6-tetramethylpiperidine 1-oxyl (TEMPO), a typical nitroxyl radical compound, produced greater current values for drugs with intramolecular hydroxy groups and secondary and tertiary amines. However, because the catalytic action of NNO is inactivated by primary amines in the substrate, VCM and teicoplanin with primary amines could not be detected. TEMPO was less active than NNO but not inactivated against primary amines. Therefore, electrochemical sensing of vancomycin was done using 4-acetamido-2,2,6,6-tetramethylpiperidine 1-oxyl (A-TEMPO), which has a greater oxidation capacity than TEMPO due to its electron-withdrawing groups. As a result, the current of A-TEMPO increased in the low concentration range of VCM as compared to TEMPO. This method also was able to quantify VCM in the concentration range of 10-100 μM, which is an important concentration range for drug monitoring in blood.

An UHPLC-UV Method for the Determination of Vancomycin in Human Serum

Objective:

To develop a rapid ultra-performance liquid chromatographic (UHPLC)-UV method for vancomycin determination in human serum for therapeutic drug monitoring (TDM).

Methods:

Human serum samples were precipitated with 10% perchloric acid, and the supernatant after centrifugation was analyzed on an ACQUITY UHPLC BEH C18 column (2.1 × 50mm, 1.7 μm) via gradient elution with a flow rate at 0.3 mL/min. The mobile phase consisted of acetonitrile and 0.005M KH2PO4 buffer (containing 0.1% triethylamine, pH 3.4). The detection wavelength was set at 210 nm, and the column temperature was set at 40°C. The total runtime was 6.0 min per analysis.

Results:

After comprehensive validation, the method was applied to determine the concentration of vancomycin in human serum. The chromatographic peaks of vancomycin and internal standard were not interfered by endogenous matrices. The Retention Time (RT) of vancomycin was 1.91 min, while the internal standard was 1.58 min. The good linearity range of vancomycin concentration was 2.5-120 μg/mL (R2>0.999). The lower Limit of Quantitation (LLOQ) was 2.5 μg/mL. The precision at three Quality Control (QC) levels (including LLOQ) was restricted within 85-115%. The extraction recovery rate of QC samples (4.0, 20.0, and 60.0 μg/mL) were 101.16%, 97.70%, and 94.90%, respectively. Inter- and intra-day precision was less than 8% (RSD). Stability tests under different storage conditions were satisfactory. In patients, the concentration of vancomycin ranged from 7.30 to 89.12 μg/mL determined by the fully validated method.

Conclusion:

The rapid sample pre-treatment procedures and short analysis time made this UHPLC-UV method suitable for therapeutic drug monitoring (TDM) of vancomycin.

Dual-emission fluorescence biosensing of vancomycin based on AIEgen-peptide conjugates and aptamer-modified Au nanoclusters

Precise doses of antibiotics are necessary to prevent bacterial drug resistance. Although fluorescent sensors are promising for quantitative analyses of antibiotics, improvements in feasibility, selectivity, and sensitivity are needed. In this study, a dual-emission fluorescence biosensor platform was developed for simple, selective, and sensitive determination of vancomycin (Van) based on a peptide conjugated with blue-emitting aggregation-induced emission luminogens (AIEgen) and aptamer-modified red-emitting gold nanoclusters (AuNCs-apt). The peptide and aptamer together recognized Van with high affinity, thus changing the fluorescence intensity at 470 nm and 650 nm, respectively. This platform displayed excellent linear correlation between the fluorescence response and a Van concentration ranging 0.01-100 μg mL^-1, and the limit of detection (LOD) was 2.79 ng mL^-1. In addition to the ability to accurately distinguish Van from glycopeptide antibiotics, the newly developed biosensor allowed for naked-eye detection of 1 μg mL^-1 Van. These results and those of serum samples and microdialysate samples support the application of this newly developed method for Van monitoring and clinical diagnosis.

Copper nanocluster-based sensor for determination of vancomycin in exhaled breath condensate: A synchronous fluorescence spectroscopy

A synchronous fluorescence spectroscopy (SFS) nanoprobe is developed for the determination of vancomycin in exhaled breath condensate (EBC) samples. The synthesized nanoprobe is copper nanoclusters (Cu NCs) and its SFS peak is located at 405 nm with Δλ = 80. The affinity of Cu NCs to complex formation with vancomycin results in blocking non-radiative e^-/h⁺ recombination defect sites on the surface of NCs and consequently enhancing the SFS signal intensity. Central composite design and response surface methodology is used for the optimization of reaction conditions. Under the optimized conditions, a linear relationship is found between the SFS intensity and the concentration of vancomycin in the range of 0.1-8 μg/mL. The validated method is applied for the determination of vancomycin in EBC of newborns receiving vancomycin treatment.

A systematic review on chromatography-based method validation for quantification of vancomycin in biological matrices

A fully validated bioanalytical methods are prerequisite for pharmacokinetic and bioequivalence studies as well as for therapeutic drug monitoring. Due to high pharmacokinetic variability and narrow therapeutic index, vancomycin requires reliable quantification methods for therapeutic drug monitoring. To identify published chromatographic based bioanalytical methods for vancomycin in current systematic review, PubMed and ScienceDirect databases were searched. The selected records were evaluated against the method validation criteria derived from international guidelines for critical assessment. The major deficiencies were identified in method validation parameters specifically for accuracy, precision and number of calibration and validation standards, which compromised the reliability of the validated bioanalytical methods. The systematic review enacts to adapt the recommended international guidelines for suggested validation parameters to make bioanalysis reliable.

Toxicity Profile and Pharmacokinetic Study of Antibiotic Mixtures, Gentamicin and Vancomycin, in Rat Plasma by Ecofriendly Liquid Chromatography Coupled Tandem Mass Spectrometry

The global burden of bacterial infection and antimicrobial resistance increases the demand to associate more than one antibiotic to fight life-threatening bacteria. Therefore, there is a great necessity to develop simple and sensitive methods for routine analysis of clinical samples. Therapeutic drug monitoring, bioequivalence, and pharmacokinetic studies are essential to ensure drug efficiency and safety. Herein, therefore, the first ecofriendly liquid chromatography -tandem mass spectrometry (LC-MS/MS) method was developed and fully validated for simultaneous determination of a commonly combined antibiotic for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin (VCM) and gentamicin (GTM), in rat plasma after parenteral administration. VCM and GTM were extracted from plasma sample using acetonitrile (ACN)/0.1% TFA-induced protein precipitation followed by the separation on an Agilent Eclipse Plus ODS (3 mm × 100 mm, 3.5 μm) column using water-enriched mobile phase consisting of water containing 0.1% THF/ACN (85:15, v/v%) at flow rates of 0.30 mL min^-1. The mass spectrometry parameters were optimized, and multiple reaction monitoring (MRM) in positive ion mode of two transitions was utilized for quantification of precursor to product ion at m/z 725.5 → 144 and 100.1 for VCM as [M + 2H]²⁺, 478.3 → 322.2 and 156.9 for GTM, and 586.3 → 162.9 and 425.3 for amikacin (AMK) internal standard, as [M + H]⁺. The current method has been validated as per U.S. FDA bioanalytical guidelines in terms of linearity, accuracy, precision, selectivity, recovery, matrix effects, and stability. The method was linear in the range of 1-2000 ng mL^-1 and 1-1000 ng mL^-1 with detection limits (S/N of 3) of 0.18 and 0.09 ng mL^-1 for VCM and GTM, respectively. The selectivity and high sensitivity allow the current method to succeed in the study of pharmacokinetic parameters and drug-drug interaction between VCM and GTM after single-dose administration. VCM increased plasma clearance and elimination rate constant of GTM when coadministered and GTM also too. The change of serum chemistry analysis and significant elevation of creatinine and BUN indicate an alteration in kidney function in group III in those given the combined antibiotics. Our finding illustrated the nephrotoxicity of the two drugs when associated. The ecofriendly, simplicity, and rapidity of the current study made it a promising method for high-throughput biomonitoring in clinical samples.

A whole blood microsampling assay for vancomycin: development, validation and application for pediatric clinical study

Background: Vancomycin is a commonly used antibiotic, which requires therapeutic drug monitoring to ensure optimal treatment. Microsampling assays are attractive tools for pediatric clinical research and therapeutic drug monitoring. Results: A LC-MS/MS method for the quantification of vancomycin in human whole blood employing volumetric absorptive microsampling (VAMS^®) devices (20 μl) was developed and validated. Vancomycin was stable in human whole blood VAMS under assay conditions. Stability for vancomycin was established for at least 160 days as dried microsamples at -78°C. Conclusion: This method is currently being utilized for the quantitation of vancomycin in whole blood VAMS for an ongoing pediatric clinical study and representative clinical data are reported.

Population pharmacokinetic meta-analysis of individual data to design the first randomized efficacy trial of vancomycin in neonates and young infants

OBJECTIVES

In the absence of consensus, the present meta-analysis was performed to determine an optimal dosing regimen of vancomycin for neonates.

METHODS

A 'meta-model' with 4894 concentrations from 1631 neonates was built using NONMEM, and Monte Carlo simulations were performed to design an optimal intermittent infusion, aiming to reach a target AUC0-24 of 400 mg·h/L at steady-state in at least 80% of neonates.

RESULTS

A two-compartment model best fitted the data. Current weight, postmenstrual age (PMA) and serum creatinine were the significant covariates for CL. After model validation, simulations showed that a loading dose (25 mg/kg) and a maintenance dose (15 mg/kg q12h if <35 weeks PMA and 15 mg/kg q8h if ≥35 weeks PMA) achieved the AUC0-24 target earlier than a standard 'Blue Book' dosage regimen in >89% of the treated patients.

CONCLUSIONS

The results of a population meta-analysis of vancomycin data have been used to develop a new dosing regimen for neonatal use and to assist in the design of the model-based, multinational European trial, NeoVanc.

Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age

Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.

Current Status of Vancomycin Analytical Methods

BACKGROUND

The glycopeptide antibiotics are a class of antimicrobial drugs that are an important alternative for cases of bacterial infections resistant to penicillins, besides being able to be used to treat infections in people allergic to pencilin. They have great activity against Gram-positive microorganisms, including methicillin-resistant Staphylococcus aureus (MRSA), by inhibiting the cell wall synthesis.

OBJECTIVE

There are many analytical methods in the literature for determination of antimicrobial glycopeptide vancomycin in different matrixes that are very effective; however, all of them use toxic solvents, contributing to the generation of waste, causing damage to the environment and to the operator, as well as increased costs of analysis.

RESULTS

The most prevailing method found was high performance liquid chromatography (HPLC), followed by microbiological assays and, in less quantity, spectrometric methods. The chromatographic methods use organic solvents that are toxic, such as acetonitrile and methanol, and buffer solutions, that can damage the equipment and the column. In the microbiological assays the disc diffusion methods are still in the majority. The spectrophotometric methods were based in the UV-Vis region using buffer solutions as a diluent.

CONCLUSIONS

All these methods can become greener, following green analytical chemistry principles, which could bring benefits both to the environment and the operator, and reduce costs.

HIGHLIGHTS

In this paper, a literature review regarding analytical methods for determination of vancomycin was carried out with a suggestion of greener alternatives.

Electrochemical Aptamer-Based Sensors for Improved Therapeutic Drug Monitoring and High-Precision, Feedback-Controlled Drug Delivery

The electrochemical aptamer-based (E-AB) sensing platform appears to be a convenient (rapid, single-step, and calibration-free) and modular approach to measure concentrations of specific molecules (irrespective of their chemical reactivity) directly in blood and even in situ in the living body. Given these attributes, the platform may thus provide significant opportunities to render therapeutic drug monitoring (the clinical practice in which dosing is adjusted in response to plasma drug measurements) as frequent and convenient as the measurement of blood sugar has become for diabetics. The ability to measure arbitrary molecules in the body in real time could even enable closed-loop feedback control over plasma drug levels in a manner analogous to the recently commercialized controlled blood sugar systems. As initial exploration of this, we describe here the selection of an aptamer against vancomycin, a narrow therapeutic window antibiotic for which therapeutic monitoring is a critical part of the standard of care, and its adaptation into an electrochemical aptamer-based (E-AB) sensor. Using this sensor, we then demonstrate: (i) rapid (seconds) and convenient (single-step and calibration-free) measurement of plasma vancomycin in finger-prick-scale samples of whole blood, (ii) high-precision measurement of subject-specific vancomycin pharmacokinetics (in a rat animal model), and (iii) high-precision, closed-loop feedback control over plasma levels of the drug (in a rat animal model). The ability to not only track (with continuous-glucose-monitor-like measurement frequency and convenience) but also actively control plasma drug levels provides an unprecedented route toward improving therapeutic drug monitoring and, more generally, the personalized, high-precision delivery of pharmacological interventions.

Pharmacokinetic modelling and Bayesian estimation-assisted decision tools to optimize vancomycin dosage in neonates: only one piece of the puzzle

Introduction: Vancomycin is commonly administered to neonates, while observational data on therapeutic drug monitoring (TDM, trough levels) suggest that vancomycin exposure and dosage remain substandard. Area covered: Data on vancomycin pharmacokinetics (PK) and its covariates are abundant. Consequently, modeling is an obvious tool to improve targeted exposure, with a shift from TDM trough levels to area under the curve (AUC_24h) targets, as in adults. Continuous administration appeared as a practice to facilitate AUC_24h target attainment, while Bayesian model-supported targeting emerged as a novel tool. However, the AUC_24h/MIC (minimal inhibitory concentration) target itself should consider neonate-specific aspects (bloodstream infections, coagulase-negative staphylococci, protein binding, underexplored causes of variability, like assays, preparation and administration inaccuracies, or missing covariates). Expert opinion: To improve targeted exposure in neonates, initial vancomycin prescription should be based on 'a priori model-based individual dosing' using validated dosing regimens, followed by further tailoring by dosing optimization applying Bayesian estimation-assisted TDM. Future research should focus on the feasibility to integrate these tools (individualized dosing, Bayesian models) in clinical practice, and to perform PK/PD studies in the relevant animal models and human neonatal setting (coagulase-negative staphylococci, bloodstream infections).

Ready for TDM: Simultaneous quantification of amikacin, vancomycin and creatinine in human plasma employing ultra-performance liquid chromatography-tandem mass spectrometry

BACKGROUND

Amikacin (AMI) and vancomycin (VAN) are antibiotics largely used in intensive care in the empiric treatment of severe infections by multi-resistant gram-negative and gram-positive bacteria. AMI and VAN are eliminated untransformed by glomerular filtration, showing depuration ratio highly correlated with creatinine (CRE) clearance. AMI, VAN and CRE are highly polar structures, presenting poor retention in reversed-phase liquid chromatography when using conventional stationary phases.

OBJECTIVE

This study aimed to develop and validate a simple UPLC-MS/MS method for simultaneous determination of AMI, VAN, and CRE in human plasma for therapeutic drug monitoring.

RESULTS

Samples were prepared by protein precipitation, followed by dilution. Heptafluorobutyric acid (HFBA) was added to the mobile phase at low concentration (0.01%), and separation was performed in an ultra-performance reversed-phase column (particle diameter of 1.8 μm). These conditions allowed retention times of 0.92, 0.93, 2.12, 2.17 and 2.27 min for CRE, CRE-D3, AMI, KAN and VAN, respectively. The assay was linear from 0.5 to 100 mg L^-1 for AMI and VAN and 5 to 100 mg L^-1. Precision, accuracy and stability assays were acceptable according to bioanalytical validation guidelines. Suitable results. Matrix effects were in the range of +10.5 to +11.6% for AMI, -4.3 to -4.5% for VAN, and - 1.7 to +0.7 for CRE.

CONCLUSION

The first assay for the simultaneous determination of AMI, VAN and CRE in plasma by liquid chromatography-tandem mass spectrometry was reported. This assay allows the obtention of the necessary analytical data for the clinical application of population pharmacokinetic methods for therapeutic drug monitoring of AMI and VAN.

An ultra-performance liquid chromatography–tandem mass spectrometry method to quantify vancomycin in human serum by minimizing the degradation product and matrix interference

Aim: This study aimed to develop and validate a method for better therapeutic monitoring of vancomycin serum concentration. Methods & results: An ultra-performance liquid chromatography–tandem mass spectrometry (UPLC–MS/MS) method was developed and validated to minimize the interference of crystalline degradation product and matrix. It was compared with chemiluminescence microparticle immunoassay (CMIA) and ultra-performance liquid chromatography with ultraviolet detection (UPLC-UV) in the performance of testing normal, on-dialysis and hemolytic serum samples. For on-dialysis samples, a moderate correlation (r = 0.534) was observed between UPLC-UV and UPLC–MS/MS. In testing hemolytic samples, ten (10/85, 11.8%) samples were overestimated by CMIA method. Conclusion: Vancomycin concentration determined by CMIA, UPLC-UV was more affected by various panels of serum samples than UPLC–MS/MS assay, suggesting that UPLC–MS/MS is a more reliable and promising tool for clinical vancomycin therapeutic drug monitoring.

Actual body weight-based vancomycin dosing in neonates

This study aimed to explore vancomycin pharmacokinetics and its covariates in critically ill neonates and to propose an easy applicable dosing nomogram for initial treatment. Individual vancomycin pharmacokinetic parameters were calculated based on therapeutic drug monitoring data using a one-compartmental model. A linear regression model was used for examination of covariates. The mean (SD) volume of distribution (Vd) and clearance (CL) for vancomycin were 0.73 (0.31) L/kg and 0.052 (0.020) L/h/kg, respectively. Vd was related to actual body weight (ABW), gestational and postmenstrual age. CL was also associated with ABW, gestational, postmenstrual age and also creatinine clearance. ABW was the strongest predictor for vancomycin pharmacokinetics and consequently dosing. Loading dose (mg) of 11.81 × ABW (kg) + 7.86 and maintenance dose (mg/day) of 40.92 × ABW (kg) -22.18 most closely approximated pharmacokinetic target. Vancomycin pharmacokinetics was mainly influenced by ABW in neonates and a practical ABW-based dosing algorithm was developed.

A Novel Method for the Determination of Vancomycin in Serum by High-Performance Liquid Chromatography-Tandem Mass Spectrometry and Its Application in Patients with Diabetic Foot Infections

A novel, precise, and accurate high-performance liquid chromatography-tandem mass spectrometry (Q-trap-MS) method was developed, optimized, and validated for determination of vancomycin in human serum using norvancomycin as an internal standard. Effect of different parameters on the analysis was evaluated. ZORBAX SB-C18 column (150 × 4.6 mm, 5 μm) using water (containing 0.1% formic acid, v/v)⁻acetonitrile (containing 0.1% formic acid, v/v) as a mobile phase was chosen. The calibration curve was linear over the concentration ranges of 1 to 2000 ng/mL for vancomycin. The limit of detection (LOD) and limit of quantification (LOQ) for vancomycin were 0.3 and 1.0 ng/mL. Recoveries were between 87.2 and 102.3%, which gave satisfactory precision. A total of 100 serum samples (from 50 patients with diabetic foot proven Gram-positive infection and 50 nondiabetic patients with pneumonia requiring hospitalization and antibiotic therapy) were analyzed by this method. The trough vancomycin concentrations of diabetic foot infection (DFI) patients and nondiabetic patients were 8.20 ± 2.83 μg/mL (range: 4.80⁻14.2 μg/mL) and 15.80 ± 5.43 μg/mL (range: 8.60⁻19.5 μg/mL), respectively. The method is sensitive, precise, and reproducible, it could be applied for routine laboratory analysis of vancomycin in serum samples.

Modified cantilever arrays improve sensitivity and reproducibility of nanomechanical sensing in living cells

Mechanical signaling involved in molecular interactions lies at the heart of materials science and biological systems, but the mechanisms involved are poorly understood. Here we use nanomechanical sensors and intact human cells to provide unique insights into the signaling pathways of connectivity networks, which deliver the ability to probe cells to produce biologically relevant, quantifiable and reproducible signals. We quantify the mechanical signals from malignant cancer cells, with 10 cells per ml in 1000-fold excess of non-neoplastic human epithelial cells. Moreover, we demonstrate that a direct link between cells and molecules creates a continuous connectivity which acts like a percolating network to propagate mechanical forces over both short and long length-scales. The findings provide mechanistic insights into how cancer cells interact with one another and with their microenvironments, enabling them to invade the surrounding tissues. Further, with this system it is possible to understand how cancer clusters are able to co-ordinate their migration through narrow blood capillaries.

Samadhan Patil et al. report a new method for improving the sensitivity and reproducibility of mechanobiological measurements in malignant cancer cells. Their findings provide insight into the interaction of cells with each other and the microenvironment and may impact our understanding of metastasis.

Studies on the metabolism and degradation of vancomycin in simulated in vitro and aquatic environment by UHPLC-Triple-TOF-MS/MS

Vancomycin is one of the most commonly used glycopeptide antiobiotics, and as such is an important emerging environmental contaminant. Pharmaceuticals and personal care products (PPCPs), such as antibiotics, are problematic since wastewater treatment processes are not completely effective at removing these chemical compounds. Since wastewater treatment processes are not completely effective, vancomycin occurs in surface water. Vancomycin and its metabolites in vivo and degradation products in aquatic environment may lead to undesirable ecological effects that threaten the environment or cause undesirable reactions that affect human health. We aimed to study vancomycin metabolism in vitro and its natural degradation in aquatic environment, as well as explore for related metabolites and degradation products. Accordingly, we established four systems, using a constant temperature oscillator at 37 °C for 10 days for vancomycin in activated rat liver microsomes (experimental system), inactivated rat liver microsomes (control system), phosphate buffer saline (PBS system) and pure water (pure water system), as well as an additional system of activated rat liver microsomes without vancomycin (blank system). The metabolism and degradation of vancomycin were studied using a high resolution and high sensitivity ultra-high performance liquid chromatography (UHPLC)-Triple-time of flight (TOF)-mass spectrometry (MS) method in positive ion mode. The compared result of activated rat liver microsomes system and inactivated rat liver microsomes system confirms that vancomycin is not metabolized in the liver. Vancomycin was degraded in the four non-blank incubation systems. The MetabolitePilot 2.0 software was used for screening the probable degradation products, as well as for establishing its associated degradation pathways. Eventually, four degradation products were identified and their chemical structures were deduced. The results of this study provide a foundation for evaluation of the effects of vancomycin and its degradation products on environmental safety and human health in the future.

Pharmacokinetic/pharmacodynamic parameters for treatment optimization of infection due to antibiotic resistant bacteria: a summary for practical purposes in children and adults

In the last years, there has been a tremendous increase in the incidence of bacterial infections due to resistant strains, especially multi-drug resistant Gram-negative bacilli. In Europe, a north to south and a west to east gradient was noticed, with more than one third of the K. pneumonia isolates being resistant to carbapenems in few countries. New antibiotics are lacking and, as a consequence, pharmacokinetic/pharmacodynamic parameters, normalized to pathogen minimal inhibitory concentration, are used with increased frequency to treat infections due to difficult-to-treat pathogens. These parameters are available at least for the adult population, but sparse in many different publications. This review wants to provide a comprehensive and 'easy to read' text for everyday practice, briefly summarizing the presently available knowledge on pharmacokinetic/pharmacodynamic parameters (normalized for minimal inhibitory concentration values) of different class drugs, that can be applied for an effective antibacterial treatment infections due to antibiotic-resistant pathogens.

An LC-MS/MS method to determine vancomycin in plasma (total and unbound), urine and renal replacement therapy effluent

AIM

Critical illness and medical interventions, such as renal replacement therapy, can cause changes to vancomycin pharmacokinetics and lead to suboptimal dosing. To comprehensively characterize vancomycin pharmacokinetic a method must measure vancomycin in a range of clinical matrices.

RESULTS

A LC-MS/MS method was developed using hydrophilic interaction liquid chromatography and microsample volumes, where possible. For all matrices, the linear concentration range was 1-100 μg/ml, interassay accuracy and precision was within 15%, and recovery above 80%. No matrix effects were observed. Calibration equivalence may be applied for some matrix combinations.

CONCLUSION

A method for the analysis of vancomycin in plasma (total, unbound), urine and renal replacement therapy effluent, suitable for use in any patient pharmacokinetic study, has been developed and validated.

Simple and rapid quantification of vancomycin in serum, urine and peritoneal/pleural effusion via UHPLC-MS/MS applicable to personalized antibiotic dosing research

Management of the therapy of life-threatening bacterial infection is extremely based on an optimal antibiotic treatment. Achieving the correct vancomycin dosage in blood and target tissues can be complicated in special situations, e.g., where large fluid sequestration and/or acute renal failure occur. A UHPLC-MS/MS method operating in electrospray (ESI) positive ion mode was applied for the determination of vancomycin in serum, urine and peritoneal/pleural effusion. Sample pretreatment was composed of dilution and simple protein precipitation where only a small volume (50μL) of serum, urine or peritoneal/pleural effusion was required. The separation of vancomycin was performed on a Meteoric Core C18 BIO column (100×4.6mm, 2.7μm) by gradient elution with 0.1% formic acid in water and acetonitrile. The total time of analysis was 4.5min. The method was found to be linear in the range of 2-60μM (or 0.5-10μM) for serum, 0.27-10μM (or 2-60μM) for peritoneal/pleural effusion and 25-300μM for urine, which was adequate for the determination of vancomycin in patient samples. The intra- and inter-day precision was below 8% RSD, and accuracy was from 89 to 104%. The UHPLC/MS-MS method offers a fast and reliable approach to determine vancomycin concentrations in three different human body fluid samples (serum, urine and peritoneal/pleural effusion) with a simple sample pretreatment that was the same for all selected specimens. This method should be applicable to large sample series in clinical (pharmacokinetic/pharmacodynamic) studies.

New liquid chromatography-tandem mass spectrometry method for routine TDM of vancomycin in patients with both normal and impaired renal functions and comparison with results of polarization fluoroimmunoassay in light of varying creatinine concentrations

A new LC-MS/MS method with simple sample extraction and a relatively short period of vancomycin analysis for routine therapeutic drug monitoring was developed and validated. 50μL serum was precipitated using 20μL 33% trichloroacetic acid and 0.5mol/L NH₄OH was added to increase pH before analysis. A RP BEH C18, 1.7μm, 2.1×50mm column maintained at 30°C and tobramycin as internal standard were used. Mass detection was performed in positive electrospray mode. The results obtained with LC-MS/MS method were correlated with an FPIA assay (Abbott AxSYM) using mouse monoclonal antibody. Subjects were divided into three groups according to creatinine levels (53.5±19.1, 150.2±48.4, 471.7±124.7μmol/L) and Passing-Bablok regression analysis and Bland-Altman analysis were used to compare vancomycin concentrations. The results of subjects with both normal and higher creatinine levels correlated very well and the linear regression model equations were near ideal (LC-MS_VAN=0.947×Abbott_VAN+0.192 and LC-MS_VAN=0.973×Abbott_VAN-0.411 respectively). Dialyzed patients with the highest creatinine levels showed about 14% greater vancomycin concentration with the FPIA assay (LC-MS_VAN=0.866×Abbott_VAN+2.127). This overestimation probably due to the presence of the metabolite CDP ought not to be of clinical relevance owing to the wide range of recommended vancomycin concentration.

High-throughput determination of vancomycin in human plasma by a cost-effective system of two-dimensional liquid chromatography

Therapeutic drug monitoring (TDM) is one of the most important services of clinical laboratories. Two main techniques are commonly used: the immunoassay and chromatography method. We have developed a cost-effective system of two-dimensional liquid chromatography with ultraviolet detection (2D-LC-UV) for high-throughput determination of vancomycin in human plasma that combines the automation and low start-up costs of the immunoassay with the high selectivity and sensitivity of the liquid chromatography coupled with mass spectrometric detection without incurring their disadvantages, achieving high cost-effectiveness. This 2D-LC system offers a large volume injection to provide sufficient sensitivity and uses simulated gradient peak compression technology to control peak broadening and to improve peak shape. A middle column was added to reduce the analysis cycle time and make it suitable for high-throughput routine clinical assays. The analysis cycle time was 4min and the peak width was 0.8min. Compared with other chromatographic methods that have been developed, the analysis cycle time and peak width for vancomycin was reduced significantly. The lower limit of quantification was 0.20μg/mL for vancomycin, which is the same as certain LC-MS/MS methods that have been recently developed and validated. The method is rapid, automated, and low-cost and has high selectivity and sensitivity for the quantification of vancomycin in human plasma, thus making it well-suited for use in hospital clinical laboratories.

Monitoring of vancomycin in human plasma via portable microchip electrophoresis with contactless conductivity detector and multi-stacking strategy

A portable microchip electrophoresis (MCE) coupled with on-chip contactless conductivity detection (C⁴D) system was evaluated for the determination of vancomycin in human plasma. In order to enhance the detection sensitivity, a new online multi-stacking preconcentration technique based on field-enhanced sample injection (FESI) and micelle-to-solvent stacking (MSS) was developed and implemented in MCE-C⁴D system equipped with a commercially available double T-junction glass chip. The cationic analytes from the two sample reservoirs were injected under FESI conditions and subsequently focused by MSS within the sample-loading channel. The proposed multi-stacking strategy was verified under a fluorescence microscope using Rhodamine 6G as the model analyte and a sensitivity enhancement factor (SEF) of up to 217 was achieved. The developed approach was subsequently implemented in the aqueous-based MCE, coupled to C⁴D in order to monitor the targeted antibiotic (in this case, vancomycin) present in human plasma samples. The multi-stacking and analysis time for vancomycin were 50s and 250s respectively, with SEF of approximately 83 when compared to typical gated injection. The detection limit of the method for vancomycin was 1.2μg/mL, with intraday and interday repeatability RSDs of 2.6% and 4.3%, respectively. Recoveries in spiked human plasma were 99.0%-99.2%.

Coagulase negative staphylococcal sepsis in neonates: do we need to adapt vancomycin dose or target?

Background

Despite differences in types of infection and causative organisms, pharmacokinetic-pharmacodynamic (PKPD) targets of vancomycin therapy derived from adult studies are suggested for neonates. We aimed to identify doses needed for the attainment of AUC/MIC > 400 and AUC/MIC > 300 in neonates with sepsis and correlate these targets with recommended doses and treatment outcome.

Methods

Neonates who had Vancomycin therapeutic drug monitoring (TDM) performed between January 1, 2010 and December 31, 2012 were studied. Clinical characteristics, episodes of Gram-positive sepsis with outcomes and all neonatal blood culture isolates in hospital were collected from medical records. To estimate probability of target attainment of AUC/MIC >400 and AUC/MIC >300 a 1000-subject Monte Carlo simulation was performed by calculating AUC using Anderson’s (Anderson et al. 2006) and TDM trough concentrations (C_trough) based population PK models.

Results

Final dataset included 76 patients; 57 with confirmed Gram-positive sepsis. TDM was taken after the 1^st to 44^th dose. 84.1% of C_trough were within the range 5–15 mg/L. Currently recommended doses achieved probability of the targets (PTA) of AUC/MIC >400 and AUC/MIC >300 in less than 25% and 40% of cases, respectively. Doses required for 80% PTA of AUC/MIC > 400 for MIC ≥2 mg/L resulted in C_trough values ≥14 mg/L. Mean AUC/MIC values were similar in treatment failure and success groups.

Conclusion

With currently recommended vancomycin dosing the therapeutic target of AUC/MIC > 400 is achieved only by 25% of neonates. Appropriate PKPD targets and respective dosing regimens need to be defined in prospective clinical studies in this population.