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Tsuda Y, Takahashi M, Watanabe F, Goto K, Echizen H. Population Pharmacokinetic Analysis of Vancomycin in Patients with Solid or Hematological Malignancy in Relation to the Quick Sequential Organ Failure Assessment Scores. Eur J Drug Metab Pharmacokinet 2023; 48:647-655. [PMID: 37695498 DOI: 10.1007/s13318-023-00850-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND AND OBJECTIVE It remains unclear whether sepsis in patients with malignancy interferes with the predictive performance of the dose-estimation formulas. The quick sequential organ failure assessment (qSOFA) score can help identify patients with poor outcomes because of sepsis-associated organ damage. Vancomycin, an important antibiotic, treats systemic infections (sepsis) caused by methicillin-resistant Staphylococcus aureus. We aimed to clarify whether including the qSOFA score in a standard population pharmacokinetic (PopPK) assessment may improve the predictive performance of vancomycin doses in patients with malignancy. METHODS This was a retrospective, observational study. Serum vancomycin concentration-time datasets were obtained from the therapeutic drug monitoring records of St. Luke's International Hospital (Tokyo, Japan) from January 2011 to August 2016. Clinical and laboratory data of the relevant patients were retrieved from electronic health records. PopPK analysis was performed using the NONMEM program, which includes creatinine clearance (CLCr), blood neutrophil counts, qSOFA scores, and type of malignancy as covariates. We examined the validity of the final PopPK model using bootstrapping, goodness-of-fit plots, and prediction-corrected visual predictive checks. RESULTS Six hundred and eight blood samples were obtained from 325 patients. In the final PopPK model, the CLCr and qSOFA scores were selected as covariates of systemic vancomycin clearance (p < 0.05): the population mean value was 2.8 (L/h). Regardless of the CLCr, a qSOFA score of greater than 1 was associated with an approximately 10% reduction in vancomycin clearance. CONCLUSIONS qSOFA scores might be an additional covariate to CLCr for estimating vancomycin concentrations with a PopPK model in patients with malignancy.
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Affiliation(s)
- Yasumasa Tsuda
- Department of Pharmacy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan.
| | - Masahiro Takahashi
- Department of Pharmacotherapy, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
| | - Fumiya Watanabe
- Department of Pharmacometrics and Pharmacokinetics, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
| | - Kazumi Goto
- Department of Pharmacy, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Hirotoshi Echizen
- Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
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Xiao Q, Zhang H, Wu X, Qu J, Qin L, Wang C. Augmented Renal Clearance in Severe Infections-An Important Consideration in Vancomycin Dosing: A Narrative Review. Front Pharmacol 2022; 13:835557. [PMID: 35387348 PMCID: PMC8979486 DOI: 10.3389/fphar.2022.835557] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/25/2022] [Indexed: 12/15/2022] Open
Abstract
Vancomycin is a hydrophilic antibiotic widely used in severe infections, including bacteremia and central nervous system (CNS) infections caused by Gram-positive bacteria such as methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci and enterococci. Appropriate antimicrobial dosage regimens can help achieve the target exposure and improve clinical outcomes. However, vancomycin exposure in serum and cerebrospinal fluid (CSF) is challenging to predict due to rapidly changing pathophysiological processes and patient-specific factors. Vancomycin concentrations may be decreased for peripheral infections due to augmented renal clearance (ARC) and increased distribution caused by systemic inflammatory response syndrome (SIRS), increased capillary permeability, and aggressive fluid resuscitation. Additionally, few studies on vancomycin’s pharmacokinetics (PK) in CSF for CNS infections. The relationship between exposure and clinical response is unclear, challenging for adequate antimicrobial therapy. Accurate prediction of vancomycin pharmacokinetics/pharmacodynamics (PK/PD) in patients with high interindividual variation is critical to increase the likelihood of achieving therapeutic targets. In this review, we describe the interaction between ARC and vancomycin PK/PD, patient-specific factors that influence the achievement of target exposure, and recent advances in optimizing vancomycin dosing schedules for severe infective patients with ARC.
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Affiliation(s)
- Qile Xiao
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Hainan Zhang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaomei Wu
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, Second Xiangya Hospital, Central South University, Changsha, China
| | - Lixia Qin
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
| | - Chunyu Wang
- Department of Neurology, Second Xiangya Hospital, Central South University, Changsha, China
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Morath B, Meid AD, Rickmann J, Soethoff J, Verch M, Karck M, Zaradzki M. Renal Safety of Hydroxyethyl starch 130/0.42 After Cardiac Surgery: A Retrospective Cohort Analysis. Drug Saf 2021; 44:1311-1321. [PMID: 34564829 PMCID: PMC8626393 DOI: 10.1007/s40264-021-01116-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2021] [Indexed: 11/27/2022]
Abstract
Introduction The risk for renal complications from hydroxyethyl starch 130/0.42 (HES) impacts treatment decisions in patients after cardiac surgery. Objective The objective of this study was to determine the impact of postoperatively administered HES on renal function and 90-day mortality compared to sole crystalloid administration in patients after elective cardiac surgery. Methods Using electronic health records from a university hospital, confounding-adjusted models analyzed the associations between postoperative HES administration and the occurrence of postoperative acute kidney injury. In addition, 90-day mortality was evaluated. The impact of HES dosage and timing on renal function on trajectories of estimated glomerular filtration rates over the postoperative period was investigated using linear mixed-effects models. Results Overall 1009 patients (45.0%) experienced acute kidney injury. Less acute kidney injury occurred in patients receiving HES compared with patients receiving only crystalloids for fluid resuscitation (43.7% vs 51.2%, p = 0.008). In multivariate acute kidney injury models, HES had a protective association (odds ratio: 0.89; 95% confidence interval 0.82–0.96). Crystalloids were not as protective as HES (odds ratio: 0.98; 95% confidence interval 0.95–1.00). There was no association between HES and 90-day mortality (odds ratio: 1.05; 95% confidence interval 0.88–1.25). Renal function trajectories were dose dependent and biphasic, HES appeared to slow down the late postoperative decline. Conclusions This study showed no association between HES and the postoperative occurrence of acute kidney injury and thus further closes the evidence gap on HES safety in cardiac surgery patients. Although this was a retrospective cohort study, the results indicated that HES might be safely administered to cardiac surgery patients with regard to renal outcomes, especially if it was administered early and dosed appropriately. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-021-01116-5.
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Affiliation(s)
- Benedict Morath
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
- Cooperation Unit Clinical Pharmacy, Heidelberg University, Heidelberg, Germany
- Hospital Pharmacy, Heidelberg University Hospital, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Rickmann
- Center for Information and Medical Technology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jasmin Soethoff
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus Verch
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany.
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Population Pharmacokinetics and Outcomes of Critically Ill Pediatric Patients Treated with Intravenous Colistin at Higher Than Recommended Doses. Antimicrob Agents Chemother 2021; 65:AAC.00002-21. [PMID: 33782000 PMCID: PMC8316147 DOI: 10.1128/aac.00002-21] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 03/18/2021] [Indexed: 12/18/2022] Open
Abstract
Limited pharmacokinetic (PK) data suggest that currently recommended pediatric dosages of colistimethate sodium (CMS) by the Food and Drug Administration and European Medicines Agency may lead to suboptimal exposure, resulting in plasma colistin concentrations that are frequently <2 mg/liter. We conducted a population PK study in 17 critically ill patients 3 months to 13.75 years (median, 3.3 years) old who received CMS for infections caused by carbapenem-resistant Gram-negative bacteria. CMS was dosed at 200,000 IU/kg/day (6.6 mg colistin base activity [CBA]/kg/day; 6 patients), 300,000 IU/kg/day (9.9 mg CBA/kg/day; 10 patients), and 350,000 IU/kg/day (11.6 mg CBA/kg/day; 1 patient). Plasma colistin concentrations were determined using ultraperformance liquid chromatography combined with electrospray ionization-tandem mass spectrometry. Colistin PK was described by a one-compartment disposition model, including creatinine clearance, body weight, and the presence or absence of systemic inflammatory response syndrome (SIRS) as covariates (P < 0.05 for each). The average colistin plasma steady-state concentration (Css,avg) ranged from 1.11 to 8.47 mg/liter (median, 2.92 mg/liter). Ten patients had Css,avg of ≥2 mg/liter. The presence of SIRS was associated with decreased apparent clearance of colistin (47.8% of that without SIRS). The relationship between the number of milligrams of CBA per day needed to achieve each 1 mg/liter of plasma colistin Css,avg and creatinine clearance (in milliliters per minute) was described by linear regression with different slopes for patients with and without SIRS. Nephrotoxicity, probably unrelated to colistin, was observed in one patient. In conclusion, administration of CMS at the above doses improved exposure and was well tolerated. Apparent clearance of colistin was influenced by creatinine clearance and the presence or absence of SIRS.
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Population Pharmacokinetics of Vancomycin Under Continuous Renal Replacement Therapy Using a Polymethylmethacrylate Hemofilter. Ther Drug Monit 2021; 42:452-459. [PMID: 31913865 DOI: 10.1097/ftd.0000000000000721] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although continuous hemodiafiltration (CHDF) is often performed in critically ill patients during sepsis treatment, the pharmacokinetics of vancomycin (VCM) during CHDF with a polymethylmethacrylate hemofilter (PMMA-CHDF) have not been revealed. In this study, the authors aimed to describe the population pharmacokinetics of VCM in critically ill patients undergoing PMMA-CHDF and clarify its hemofilter clearance (CLhemofilter). METHODS This single-center, retrospective study enrolled patients who underwent intravenous VCM therapy during PMMA-CHDF at the intensive care unit of Chiba University Hospital between 2008 and 2016. A population analysis was performed, and CLhemofilter was assessed. RESULTS Twenty-five patients were enrolled. Median body weight (BW) and Sequential Organ Failure Assessment (SOFA) score were 63 kg and 15, respectively. Mean conditions for CHDF were 107.5 ± 18.3 mL/min for blood flow rate and 26.3 ± 6.3 mL/kg/h for effluent flow rate. The mean parameter estimates were distribution volume of the central compartment (V1), 59.1 L; clearance of the central compartment (CL1), 1.35 L/h; distribution volume of the peripheral compartment (V2), 56.1 L; and clearance of the peripheral compartment (CL2), 3.65 L/h. BW and SOFA score were significantly associated with V1 (P < 0.05) and CL1 (P < 0.05), respectively, and were thus selected as covariates in the final model. The estimated dosage of VCM to achieve a target area under the concentration-time curve/minimum inhibitory concentration ≥400 was 27.1 mg/kg for loading and 9.7 mg/kg every 24 hours for maintenance; these dosages were affected by BW and SOFA score. Mean CLhemofilter obtained from 8 patients was 1.35 L/h, which was similar to CL1. CONCLUSIONS The authors clarified the pharmacokinetics and CLhemofilter of VCM in PMMA-CHDF patients. The PK of VCM in patients undergoing CHDF appeared to vary not only with the CHDF setting and BW but also with SOFA score.
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Perin N, Roger C, Marin G, Molinari N, Evrard A, Lavigne JP, Barbar S, Claret PG, Boutin C, Muller L, Lipman J, Lefrant JY, Jaber S, Roberts JA. Vancomycin Serum Concentration after 48 h of Administration: A 3-Years Survey in an Intensive Care Unit. Antibiotics (Basel) 2020; 9:antibiotics9110793. [PMID: 33182613 PMCID: PMC7698174 DOI: 10.3390/antibiotics9110793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022] Open
Abstract
The present study assessed the proportion of intensive care unit (ICU) patients who had a vancomycin serum concentration between 20 and 25 mg/L after 24–48 h of intravenous vancomycin administration. From 2016 to 2018, adult ICU patients with vancomycin continuous infusion (CI) for any indication were included. The primary outcome was the proportion of patients with a first-available vancomycin serum concentration between 20–25 mg/L at 24 h (D2) or 48 h (D3). Of 3894 admitted ICU patients, 179 were included. A median loading dose of 15.6 (interquartile range (IQR) = (12.5–20.8) mg/kg) was given in 151/179 patients (84%). The median daily doses of vancomycin infusion for D1 and D2 were 2000 [(IQR (1600–2000)) and 2000 (IQR (2000–2500)) mg/d], respectively. The median duration of treatment was 4 (2–7) days. At D2 or D3, the median value of first serum vancomycin concentration was 19.8 (IQR (16.0–25.1)) with serum vancomycin concentration between 20–25 mg/L reported in 43 patients (24%). Time spent in the ICU before vancomycin initiation was the only risk factor of non-therapeutic concentration at D2 or D3. Acute kidney injury occurred significantly more when vancomycin concentration was supra therapeutic at D2 or D3. At D28, 44 (26%) patients had died. These results emphasize the need of appropriate loading dose and regular monitoring to improve vancomycin efficacy and avoid renal toxicity.
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Affiliation(s)
- Nicolas Perin
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- Correspondence:
| | - Claire Roger
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Grégory Marin
- IMAG, CNRS, Université de Montpellier, Department of Statistics, CHU Montpellier, 34295 Montpellier, France; (G.M.); (N.M.)
| | - Nicolas Molinari
- IMAG, CNRS, Université de Montpellier, Department of Statistics, CHU Montpellier, 34295 Montpellier, France; (G.M.); (N.M.)
| | - Alexandre Evrard
- Laboratoire de Biochimie, Centre Hospitalier Universitaire (CHU) de Nîmes, Hôpital Carémeau, 30029 Nîmes, France;
| | - Jean-Philippe Lavigne
- VBMI, INSERM U1047, Université de Montpellier, Laboratoire de Microbiologie, CHU de Nîmes, 30029 Nîmes, France;
| | - Saber Barbar
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Pierre Géraud Claret
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Caroline Boutin
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Laurent Muller
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Jeffrey Lipman
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- VBMI, INSERM U1047, Université de Montpellier, Laboratoire de Microbiologie, CHU de Nîmes, 30029 Nîmes, France;
- Department of Intensive Care Medicine, Royal Brisbane and Womens’ Hospital, Brisbane 4029, QLD, Australia
- UQ Centre for Clinical Research, The University of Queensland, Brisbane 4029, QLD, Australia
| | - Jean-Yves Lefrant
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
| | - Samir Jaber
- Département d’Anesthésie Réanimation B, Saint Eloi ICU, Montpellier University Hospital, 34295 Montpellier, France;
| | - Jason A. Roberts
- Service des Réanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, 30029 Nîmes, France; (C.R.); (S.B.); (P.G.C.); (C.B.); (L.M.); (J.L.); (J.-Y.L.); (J.A.R.)
- Equipe D’accueil 2992 Caractéristiques Féminines des Interfaces Vasculaires, Faculté de Médecine, Université de Montpellier, 34090 Montpellier, France
- UQ Centre for Clinical Research, The University of Queensland, Brisbane 4029, QLD, Australia
- Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane 4029, QLD, Australia
- Pharmacy Department, Royal Brisbane and Womens’ Hospital, Brisbane 4029, QLD, Australia
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Zhou Q, Zhao F, Wang M. An individualized administration model of vancomycin in elderly patients with sepsis and factors influencing augmented renal clearance. J Clin Pharm Ther 2020; 46:447-453. [PMID: 33210363 DOI: 10.1111/jcpt.13304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/02/2020] [Accepted: 10/06/2020] [Indexed: 12/21/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Vancomycin efficacy is dependent on appropriate dosing, which should aim to achieve a target serum trough level. The purpose of this study was to determine the variables that predicted vancomycin serum trough concentrations in elderly patients with sepsis. METHODS This retrospective cohort study, which was conducted in the medical ICU of a university-affiliated teaching hospital in China, included 87 medical patients with sepsis who were enrolled from January 2014 to December 2017. RESULTS AND DISCUSSION All the patients were at least 60 years old (mean age = 74.8 ± 8.2 years), and 51.7% (n = 45) of them were male. The most common primary site of infection was the lungs (67.8%), followed by the abdomen (12.6%). Patients with septic shock accounted for 21.8% (n = 19) of the cases. The proportion of patients with vancomycin serum trough concentrations reaching target concentrations (≥15 mg/L) was 47.1% (41 cases). Multivariate linear regression showed that the creatinine clearance rate (CCR) and the daily dosage of vancomycin were independent predictors of vancomycin serum trough concentrations (both p's < 0.05), and the model for predicting vancomycin trough concentrations should be: serum trough concentration (mg/L) = 15.942 - 0.101 × CCR (mL/min) + 0.347 × vancomycin daily doses (mg/kg/d). Augmented renal clearance (ARC) was present in 13 patients (14.9%), and logistic regression revealed body mass index (OR = 1.420, p = .002) and serum creatinine level (OR = 0.883, p = .002) were independent predictors of ARC. WHAT IS NEW AND CONCLUSION The CCR and daily dosage of vancomycin were significantly correlated with vancomycin serum trough concentrations in elderly patients with sepsis, and the individualized administration model should be verified through further clinical trials. BMI and serum creatinine level were identified to be independent predictors of ARC in elderly patients.
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Affiliation(s)
- Qingtao Zhou
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Feifan Zhao
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
| | - Meng Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China
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Response to: Is vancomycin clearance really correlated with hemoglobin? Arguments that it’s not. Eur J Clin Pharmacol 2019; 75:1619-1620. [DOI: 10.1007/s00228-019-02728-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/17/2019] [Indexed: 11/26/2022]
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Chuma M, Makishima M, Imai T, Tochikura N, Suzuki S, Kuwana T, Sawada N, Iwabuchi S, Sekimoto M, Nakayama T, Sakaue T, Kikuchi N, Yoshida Y, Kinoshita K. Relationship between hemoglobin levels and vancomycin clearance in patients with sepsis. Eur J Clin Pharmacol 2019; 75:929-937. [PMID: 30868193 DOI: 10.1007/s00228-019-02661-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/03/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE It is important to accurately estimate accurate vancomycin (VCM) clearance (CLvcm) for appropriate VCM dosing in the treatment of patients with sepsis. However, the pathophysiology of sepsis can make CLvcm prediction less accurate. Clearance of hydrophilic antibiotics is disturbed by organ dysfunction, and hemoglobin levels are negatively correlated with sequential organ function assessment scores. We investigated whether hemoglobin levels are associated with CLvcm in sepsis patients. METHODS We performed a retrospective cohort study of patients treated with VCM in the Emergency and Critical Care Center of Nihon University Itabashi Hospital between 2005 and 2015. We enrolled 72 patients after exclusion of patients who received renal replacement therapy or surgery, had a change in hemoglobin levels more than 2 g/dL or received an erythrocyte infusion during the interval between initial VCM administration and measurement of initial trough levels, had a serum baseline creatinine level of ≥ 2 mg/dL, or were under 18 years old. RESULTS Enrolled patients consisted of 13 non-sepsis patients and 59 sepsis patients. In sepsis patients, although CLvcm was correlated with CrCl in HGB ≥ 9 group as well as in non-sepsis patients, its correlation was not observed in HGB < 9 group. Hemoglobin levels were correlated with CLvcm in sepsis patients but not in non-sepsis patient. Multiple linear regression analysis also indicated that lower CLvcm was associated with lower hemoglobin and CrCl. CONCLUSION Lower hemoglobin levels influence a relationship between CLvcm and CrCl in sepsis patients. We propose that VCM dosing should be adjusted for hemoglobin levels in sepsis patients.
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Affiliation(s)
- Masayuki Chuma
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan.,Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Makoto Makishima
- Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Toru Imai
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Naohiro Tochikura
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Shinichiro Suzuki
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Tsukasa Kuwana
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Nami Sawada
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - So Iwabuchi
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Masao Sekimoto
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takahiro Nakayama
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takako Sakaue
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | | | - Yoshikazu Yoshida
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
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Relationship Between Initial Vancomycin Trough Levels and Early-Onset Vancomycin-Associated Nephrotoxicity in Critically Ill Patients. Ther Drug Monit 2018; 40:109-114. [PMID: 29095798 DOI: 10.1097/ftd.0000000000000459] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Appropriate initial dosing of vancomycin (VCM) is important in improving survival and in preventing nephrotoxicity in critically ill patients, but the potential relationship between initial VCM trough levels and early-onset nephrotoxicity remains unclear. We examined the relationship between initial VCM trough levels and early-onset VCM-associated nephrotoxicity. METHODS We performed a retrospective study of patients who had therapeutic drug monitoring of VCM with initial trough levels within 4 days after the beginning of VCM administration. We excluded patients who received renal replacement therapy from 2 days before to 7 days after the beginning of VCM administration, were younger than 18 years, or had renal dysfunction before the beginning of VCM administration. Early-onset VCM-associated nephrotoxicity was defined as an increase in serum creatinine level of ≥0.5 mg/dL (44.2 μmol/L) or 50% above baseline for 2 or more consecutive days within 7 days after the beginning of VCM administration. RESULTS Among 109 enrolled patients, 13 patients had early-onset VCM-associated nephrotoxicity. Its incidence rate was 31.3% in patients with initial trough levels of ≥20g/mL, which was significantly higher than 6.3% in patients with initial trough levels of <10 mg/L. Multiple logistic regression analysis demonstrated that early-onset VCM-associated nephrotoxicity was associated with initial trough levels of ≥20 mg/L (odds ratio, 5.0; 95% confidence interval, 1.3-19.1) and with vasopressor use (odds ratio, 5.0; 95% confidence interval, 1.3-19.1). Kaplan-Meier analysis showed that the probability of nonnephrotoxicity for patients with initial VCM trough levels of ≥20 mg/L was lower compared with patients with trough levels of <15 mg/L. CONCLUSIONS Initial trough levels of ≥20 mg/L but not ≥15 mg/L were associated with early-onset VCM-associated nephrotoxicity in critically ill patients. Future prospective studies are needed to examine outcomes in critically ill patients achieving initial VCM trough levels of 15-20 mg/L.
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Monteiro JF, Hahn SR, Gonçalves J, Fresco P. Vancomycin therapeutic drug monitoring and population pharmacokinetic models in special patient subpopulations. Pharmacol Res Perspect 2018; 6:e00420. [PMID: 30156005 PMCID: PMC6113434 DOI: 10.1002/prp2.420] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/20/2018] [Indexed: 01/02/2023] Open
Abstract
Vancomycin is a fundamental antibiotic in the management of severe Gram-positive infections. Inappropriate vancomycin dosing is associated with therapeutic failure, bacterial resistance and toxicity. Therapeutic drug monitoring (TDM) is acknowledged as an important part of the vancomycin therapy management, at least in specific patient subpopulations, but implementation in clinical practice has been difficult because there are no consensus and agglutinator documents. The aims of the present work are to present an overview of the current knowledge on vancomycin TDM and population pharmacokinetic (PPK) models relevant to specific patient subpopulations. Based on three published international guidelines (American, Japanese and Chinese) on vancomycin TDM and a bibliographic review on available PPK models for vancomycin in distinct subpopulations, an analysis of evidence was carried out and the current knowledge on this topic was summarized. The results of this work can be useful to redirect research efforts to address the detected knowledge gaps. Currently, TDM of vancomycin presents a moderate level of evidence and practical recommendations with great robustness in neonates, pediatric and patients with renal impairment. However, it is important to investigate in other subpopulations known to present altered vancomycin pharmacokinetics (eg neurosurgical, oncological and cystic fibrosis patients), where evidence is still unsufficient.
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Affiliation(s)
- Joaquim F. Monteiro
- Faculdade de Medicina da Universidade do Porto (FMUP)PortoPortugal
- Instituto de Investigação e Formação Avançadas em Ciências e Tecnologias da Saúde (IINFACTS)Instituto Universitário de Ciências da Saúde (IUCS)GandraPortugal
| | - Siomara R. Hahn
- Instituto de Ciências BiológicasCurso de FarmáciaUniversidade de Passo Fundo (UPF)Passo FundoBrasil
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
| | - Jorge Gonçalves
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
| | - Paula Fresco
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
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Imai T. [Evaluation of Pharmacotherapy on Emergency and Intensive Care Medicine: The Influence of Intensity and Duration of Invasion]. YAKUGAKU ZASSHI 2018; 137:1427-1430. [PMID: 29199252 DOI: 10.1248/yakushi.17-00139-1] [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
Critically ill patients who receive high-level invasion show physiological changes different from those under more normal conditions, along with variable therapeutic effects and pharmacokinetics. The concept of systemic inflammatory response syndrome (SIRS) has been introduced to describe the clinical state resulting from invasive actions taken under acute circumstances, resulting in an acute-phase systemic response. In particular, dosages of vancomycin (VCM) and phenytoin (PHT) need to be adjusted by therapeutic drug monitoring (TDM) because of their narrow therapeutic concentration windows. However, there are few reports on the pharmacokinetics of VCM and PHT in patients with SIRS. We performed a retrospective cohort study of patients treated with VCM and PHT. These studies suggest that the pharmacokinetics of VCM are affected by SIRS score and duration. Furthermore, the concentration of PHT was also shown to be higher in SIRS patients compared with non-SIRS patients. These findings suggest that the pharmacokinetics of VCM and PHT may be affected by the pathology of SIRS, rather than by other patient characteristics. Modifying dosing according to SIRS will improve the prediction accuracy of drug concentration based on TDM. In this review, I introduce work conducted by pharmacists in the clinical study of critically ill patients, and will be discussing the evaluation of pharmacotherapy in emergency and intensive care medicine.
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Affiliation(s)
- Toru Imai
- Department of Pharmacy, Nihon University Itabashi Hospital
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