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van der Veer MAA, de Haan TR, Franken LGW, van Hest RM, Groenendaal F, Dijk PH, de Boode WP, Simons S, Dijkman KP, van Straaten HLM, Rijken M, Cools F, Nuytemans DHGM, van Kaam AH, Bijleveld YA, Mathôt RAA. Population pharmacokinetics of vancomycin in term neonates with perinatal asphyxia treated with therapeutic hypothermia. Br J Clin Pharmacol 2024; 90:1418-1427. [PMID: 38450797 DOI: 10.1111/bcp.16026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/18/2024] [Accepted: 01/31/2024] [Indexed: 03/08/2024] Open
Abstract
AIMS Little is known about the population pharmacokinetics (PPK) of vancomycin in neonates with perinatal asphyxia treated with therapeutic hypothermia (TH). We aimed to describe the PPK of vancomycin and propose an initial dosing regimen for the first 48 h of treatment with pharmacokinetic/pharmacodynamic target attainment. METHODS Neonates with perinatal asphyxia treated with TH were included from birth until Day 6 in a multicentre prospective cohort study. A vancomycin PPK model was constructed using nonlinear mixed-effects modelling. The model was used to evaluate published dosing guidelines with regard to pharmacokinetic/pharmacodynamic target attainment. The area under the curve/minimal inhibitory concentration ratio of 400-600 mg*h/L was used as target range. RESULTS Sixteen patients received vancomycin (median gestational age: 41 [range: 38-42] weeks, postnatal age: 4.4 [2.5-5.5] days, birth weight: 3.5 [2.3-4.7] kg), and 112 vancomycin plasma concentrations were available. Most samples (79%) were collected during the rewarming and normothermic phase, as vancomycin was rarely initiated during the hypothermic phase due to its nonempirical use. An allometrically scaled 1-compartment model showed the best fit. Vancomycin clearance was 0.17 L/h, lower than literature values for term neonates of 3.5 kg without perinatal asphyxia (range: 0.20-0.32 L/h). Volume of distribution was similar. Published dosing regimens led to overexposure within 24 h of treatment. A loading dose of 10 mg/kg followed by 24 mg/kg/day in 4 doses resulted in target attainment. CONCLUSION Results of this study suggest that vancomycin clearance is reduced in term neonates with perinatal asphyxia treated with TH. Lower dosing regimens should be considered followed by model-informed precision dosing.
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Affiliation(s)
- Marlotte A A van der Veer
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Timo R de Haan
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Linda G W Franken
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Peter H Dijk
- University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatrics, Division of Neonatology, University of Groningen, Groningen, The Netherlands
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Sinno Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Koen P Dijkman
- Department of Neonatology, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | | | - Monique Rijken
- Department of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Filip Cools
- Department of Neonatology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Debbie H G M Nuytemans
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Yuma A Bijleveld
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Kenneally AM, Leonhardt KR, Schadler A, Garlitz KL. Evaluation of an Empiric Vancomycin Dosing Protocol on Goal Troughs and Acute Kidney Injury in a Neonatal Intensive Care Unit. J Pediatr Pharmacol Ther 2023; 28:335-342. [PMID: 37795281 PMCID: PMC10547050 DOI: 10.5863/1551-6776-28.4.335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Indexed: 10/06/2023]
Abstract
OBJECTIVE Review the efficacy and safety of an updated empiric vancomycin dosing protocol in a neonatal intensive care unit (NICU). METHODS Retrospective chart review including neonates with postmenstrual age (PMA) less than 40 weeks without renal dysfunction who received vancomycin per protocol at a single institution's NICU before and after implementation of an updated dosing protocol. The primary outcome is the proportion of initial therapeutic troughs. Secondary outcomes include average trough, achievement of a therapeutic trough, number of days before attainment of a therapeutic trough, and proportion of acute kidney injury (AKI) during therapy. RESULTS The 2 groups were similar in gestational age, race, birth weight, PMA, and weight at time of vancomycin initiation. The post-implementation group had a higher proportion of initial therapeutic troughs (33.0% vs 55.1%) and a lower proportion of a subtherapeutic (58.7% vs 43.8%) and supratherapeutic (8.3% vs 1.1%) initial troughs (p = 0.002). The median trough was not different (9.20 vs 10.50 mg/L; p = 0.092). There was no difference in the proportions of achieving a therapeutic trough throughout therapy (69% vs 76%; p = 0.235); however, the post-implementation group achieved a therapeutic trough 1 day earlier (3 vs 2 days; p < 0.001). There was no difference in proportions of AKI developing between the pre-implementation vs post-implementation groups (10.1% vs 5.6%; p = 0.251). CONCLUSIONS Implementation of an updated vancomycin dosing protocol yielded a higher percentage of initial therapeutic vancomycin troughs and patients reached the therapeutic range 1 day earlier without increasing the proportion of AKI.
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Affiliation(s)
- Allison M. Kenneally
- Department of Pharmacy (AMK, KRL, KLG), University of Kentucky Healthcare, Lexington, KY
| | - Kelsey R. Leonhardt
- Department of Pharmacy (AMK, KRL, KLG), University of Kentucky Healthcare, Lexington, KY
| | - Aric Schadler
- Department of Pediatrics (AS), Kentucky Children’s Hospital, Lexington, KY
| | - Karen L. Garlitz
- Department of Pharmacy (AMK, KRL, KLG), University of Kentucky Healthcare, Lexington, KY
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Alrahahleh D, Xu S, Zhu Z, Toufaili H, Luig M, Kim HY, Alffenaar JW. An Audit to Evaluate Vancomycin Therapeutic Drug Monitoring in a Neonatal Intensive Care Unit. Ther Drug Monit 2022; 44:651-658. [PMID: 35383737 DOI: 10.1097/ftd.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is routinely used for optimization of vancomycin therapy, because of exposure-related efficacy and toxicity, in addition to significant variability in pharmacokinetics, which leads to unpredictable drug exposure. OBJECTIVE The aim of this study was to evaluate target attainment and TDM of vancomycin in neonates. METHODS The authors conducted a retrospective study and collected data from medical records of all neonates who received vancomycin therapy in the neonatal intensive care unit between January 2019 and December 2019. The primary outcome was the proportion of vancomycin courses that reached target trough concentrations of 10-20 mg/L based on appropriate TDM samples collection. Secondary outcomes included proportion of courses with appropriate dose and dose frequency, and proportion of patients who achieved target concentrations after the first dose adjustment. RESULTS In total, 69 patients were included, with 129 vancomycin courses. The median initial vancomycin trough concentration was 12 (range: 4-36) mg/L. The target trough concentration was achieved in 75% of courses after the initial dose with appropriate TDM, and 84% of courses after TDM-guided dose adjustments. Patients were dosed appropriately in 121/129 courses and TDM was performed correctly according to protocol in 51/93 courses. A dose adjustment was performed in 18/29 courses, to increase target attainment. CONCLUSIONS This study showed that there is a need for an increase in dose to improve target attainment. There is also a need to explore more effective TDM strategies to increase the proportion of neonatal patients attaining vancomycin target trough concentrations.
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Affiliation(s)
- Dua'a Alrahahleh
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
| | - Sophia Xu
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
| | - Zhaowen Zhu
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Hassan Toufaili
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia ; and
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
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Simeoli R, Cairoli S, Decembrino N, Campi F, Dionisi Vici C, Corona A, Goffredo BM. Use of Antibiotics in Preterm Newborns. Antibiotics (Basel) 2022; 11:antibiotics11091142. [PMID: 36139921 PMCID: PMC9495226 DOI: 10.3390/antibiotics11091142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.
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Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Nunzia Decembrino
- Neonatal Intensive Care Unit, University Hospital “Policlinico-San Marco” Catania, Integrated Department for Maternal and Child’s Health Protection, 95100 Catania, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
- Correspondence: ; Tel.: +39-0668592174; Fax: + 39-0668593009
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Hovey SW, Jacobson JL, Welsh KM, Vu BN. Implementation of a Pharmacist-Driven Vancomycin and Aminoglycoside Dosing Service in a Pediatric Hospital. J Pediatr Pharmacol Ther 2022; 27:340-346. [DOI: 10.5863/1551-6776-27.4.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/24/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Pharmacy-driven antibiotic dosing services have been shown to improve clinical outcomes in adult patients. This study evaluated the effect of a pharmacist-driven antimicrobial dosing service on the percentage of therapeutic serum concentrations achieved following initial vancomycin or aminoglycoside dosing regimens. A secondary objective was to determine the effect of the dosing service on nephrotoxicity in pediatric patients.
METHODS
This single-center, retrospective study used data obtained from an electronic medical record to evaluate the utility of a pharmacist-driven vancomycin or aminoglycoside dosing protocol. Assessments of target, subtherapeutic, and supratherapeutic serum concentrations were evaluated. The occurrence of changes in serum creatinine and presentation of acute kidney injury (AKI) were also determined.
RESULTS
The incidence (n [%]) of a therapeutic initial serum concentration was not statistically significant between pre-protocol and post-protocol groups (21 [46.7%] vs 22 [48.9%], respectively; p = 0.834). The incidence of initial supratherapeutic concentrations (19 [42.2%] vs 7 [15.6%]; p = 0.005) and the average number of supratherapeutic concentrations per antibiotic course (0.76 vs 0.26; p = 0.01) were higher in the pre-protocol group compared with the post-protocol group. The incidence of AKI was significantly lower in the post-protocol group (2.2% vs 13.3%; p = 0.049).
CONCLUSIONS
Implementation of a pharmacist-driven dosing service did not affect the likelihood of achieving an initial therapeutic concentration. However, it did reduce the likelihood of both supratherapeutic concentrations and AKI. Additional studies in pediatric patients are needed to affirm the use of pharmacist dosing services.
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Affiliation(s)
- Sara W. Hovey
- Rush University Medical Center (SWH, JLJ, KMW, BNV), Rush Children's Hospital, Chicago, IL; Chicago State University (BNV), College of Pharmacy, Chicago, IL
| | - Jessica L. Jacobson
- Rush University Medical Center (SWH, JLJ, KMW, BNV), Rush Children's Hospital, Chicago, IL; Chicago State University (BNV), College of Pharmacy, Chicago, IL
| | - Kristen M. Welsh
- Rush University Medical Center (SWH, JLJ, KMW, BNV), Rush Children's Hospital, Chicago, IL; Chicago State University (BNV), College of Pharmacy, Chicago, IL
| | - Betty N. Vu
- Rush University Medical Center (SWH, JLJ, KMW, BNV), Rush Children's Hospital, Chicago, IL; Chicago State University (BNV), College of Pharmacy, Chicago, IL
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Alrahahleh D, Xu S, Luig M, Kim HY, Alffenaar JW. Dosing of vancomycin and target attainment in neonates: a systematic review. Int J Antimicrob Agents 2022; 59:106515. [PMID: 35031450 DOI: 10.1016/j.ijantimicag.2021.106515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/03/2021] [Accepted: 12/22/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Neonatal infections caused by Gram-positive bacteria are commonly treated with vancomycin. However, there is a lack of agreement on the optimal vancomycin dosing regimen and corresponding vancomycin exposure to correlate with efficacy and toxicity. OBJECTIVES This review aimed to evaluate dosing of vancomycin in neonates, therapeutic target attainment and clinical toxicity and efficacy outcomes. METHODS Two electronic databases - Embase and PubMed (Medline) - were systematically searched between 1995-2020. Studies that reported dosing regimens, drug concentrations, toxicity, and efficacy of vancomycin in neonates were eligible for inclusion. Descriptive analysis and a narrative synthesis were performed. RESULTS The systematic review protocol was registered with the PROSPERO International Prospective Register of Systematic reviews in 2020 (registration number: CRD42020219568). Twenty-four studies were included for final analysis. Overall, the data from the included studies showed a great degree of heterogeneity. Therapeutic drug monitoring practices were different between institutions. Although most studies used trough concentration with a target range of 10-20 mg/L, target attainment was different across the studies. The probability of target attainment was < 80% in all tested dosing algorithms. Few studies reported on vancomycin efficacy and toxicity. CONCLUSION This is a comprehensive overview of dosing strategies of vancomycin in neonates. There was inadequate evidence to propose an optimal therapeutic regimen in the newborn population, based on the data obtained, due to the heterogeneity in the design and objectives of the included studies. Consistent and homogeneous comparative randomised clinical trials are needed to identify a dosing regimen with a probability of target attainment of > 90% without toxicity.
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Affiliation(s)
- Dua'A Alrahahleh
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Westmead Hospital, Westmead, NSW, Australia
| | - Sophia Xu
- Department of Pharmacy, Westmead Hospital, Westmead, NSW, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Westmead Hospital, Westmead, NSW, Australia; Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Westmead Hospital, Westmead, NSW, Australia; Sydney Institute for Infectious Diseases, The University of Sydney, Camperdown, NSW, Australia.
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Dawoud TH, Khan N, Afzal U, Varghese N, Rahmani A, Abu-Sa'da O. Assessment of initial vancomycin trough levels and risk factors of vancomycin-induced nephrotoxicity in neonates. Eur J Hosp Pharm 2022; 29:44-49. [PMID: 34930794 PMCID: PMC8717783 DOI: 10.1136/ejhpharm-2019-002181] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Vancomycin is a glycopeptide antibiotic commonly used in neonatal intensive care units (NICUs) to treat late onset sepsis. It is recommended that vancomycin trough levels at steady state following intermittent dosing regimen be maintained at 10-20 mg/L, which is largely dependent on the type of infection. Our objective is to assess the ability of initial vancomycin dosing regimens to obtain target trough levels and to assess the percentage and risk factors associated with the development of acute kidney injury (AKI) while on vancomycin. METHODS This is a retrospective review of all NICU patients admitted between January 2016 and December 2017 who received vancomycin according to the NeoFax at either 10 mg/kg/dose (low-dose group, LDG) or 15 mg/kg/dose (high-dose group, HDG), with a frequency based on the postmenstrual age (PMA) and postnatal age (PNA). Both regimens were compared by their ability to attain target trough levels and the episodes of vancomycin-induced AKI. Other outcomes included identification of risk factors associated with the development of vancomycin-induced nephrotoxicity. RESULTS Of 182 patients evaluated, 44 (24%) were in the LDG and 138 patients (76%) were in the HDG. Ninety-one patients (50%) attained target trough levels of 10-20 mg/L. Among these and according to patients' PMA, 48% in the HDG versus 7% in the LDG in PMA ≤29 weeks and 69% in the HDG versus 18% in the LDG in PMA 30-36 weeks attained target trough levels (p=0.006 and p<0.001, respectively). According to PNA, 47% in the HDG versus none in the LDG in patients <7 days old and 61% in the HDG versus 10% in the LDG in patients aged 8-14 days attained target trough levels (p=0.025 and p=0.016, respectively). A total of 14% developed AKI in the LDG vs 7% in the HDG (p=0.225). Only PMA ≤29 weeks (OR, 4.5, 95% CI 1.5 to 13), vancomycin trough levels >20 mg/L (OR 5.1, 95% CI 1.5 to 17), hypotension (OR 11.02, 95% CI 3.5 to 34) and furosemide (OR 4.4, 95% CI 1.4 to 13.5) were significantly associated with vancomycin-induced AKI in our NICU. CONCLUSION Vancomycin dosing in neonates according to the NeoFax did not provide sufficient attainment of target trough levels (10-20 mg/L). However, using the higher dosing range at 15 mg/kg/dose was more likely to reach target levels, with no measured increased risk of nephrotoxicity. Extreme premature neonates, supratherapeutic vancomycin trough levels, hypotension and furosemide use are associated with an increased incidence of vancomycin-induced nephrotoxicity.
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Affiliation(s)
- Tasnim Heider Dawoud
- Pharmacy - Clinical Pharmacy, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Nusrat Khan
- Paediatrics - NICU, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Uzma Afzal
- Paediatrics - NICU, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Nisha Varghese
- Paediatrics - NICU, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Aiman Rahmani
- Paediatrics - NICU, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
| | - Omar Abu-Sa'da
- Paediatrics - NICU, Tawam Hospital, Al Ain, Abu Dhabi, United Arab Emirates
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8
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Olafuyi O, Abbasi MY, Allegaert K. Physiologically based pharmacokinetic modelling of acetaminophen in preterm neonates-The impact of metabolising enzyme ontogeny and reduced cardiac output. Biopharm Drug Dispos 2021; 42:401-417. [PMID: 34407204 DOI: 10.1002/bdd.2301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/14/2021] [Accepted: 07/19/2021] [Indexed: 12/20/2022]
Abstract
In preterm neonates, physiologically based pharmacokinetic (PBPK) models are suited for studying the effects of maturational and non-maturational factors on the pharmacokinetics of drugs with complex age-dependent metabolic pathways like acetaminophen (APAP). The aim of this study was to determine the impact of drug metabolising enzymes ontogeny on the pharmacokinetics of APAP in preterm neonates and to study the effect of reduced cardiac output (CO) on its PK using PBPK modelling. A PBPK model for APAP was first developed and validated in adults and then scaled to paediatric age groups to account for the effect of enzyme ontogeny. In preterm neonates, CO was reduced by 10%, 20%, and 30% to determine how this might affect APAP PK in preterm neonates. In all age groups, the predicted concentration-time profiles of APAP were within 5th and 95th percentile of the clinically observed concentration-time profiles and the predicted Cmax and AUC were within 2-folds of the reported parameters in clinical studies. Sulfation accounted for most of APAP metabolism in children, with the highest contribution of 68% in preterm neonates. A reduction in CO by up to 30% did not significantly alter the clearance of APAP in preterm neonates. The model successfully incorporated the ontogeny of drug metabolising enzymes involved in APAP metabolism and adequately predicted the PK of APAP in preterm neonates. A reduction in hepatic perfusion as a result of up to 30% reduction in CO has no effect on the PK of APAP in preterm neonates.
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Affiliation(s)
- Olusola Olafuyi
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | | | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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9
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Abduljalil K, Pan X, Pansari A, Jamei M, Johnson TN. A Preterm Physiologically Based Pharmacokinetic Model. Part I: Physiological Parameters and Model Building. Clin Pharmacokinet 2021; 59:485-500. [PMID: 31583613 DOI: 10.1007/s40262-019-00825-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Developmental physiology can alter pharmacotherapy in preterm populations. Because of ethical and clinical constraints in studying this vulnerable age group, physiologically based pharmacokinetic models offer a viable alternative approach to predicting drug pharmacokinetics and pharmacodynamics in this population. However, such models require comprehensive information on the changes of anatomical, physiological and biochemical variables, where such data are not available in a single source. OBJECTIVE The objective of this study was to integrate the relevant physiological parameters required to build a physiologically based pharmacokinetic model for the preterm population. METHODS Published information on developmental preterm physiology and some drug-metabolising enzymes were collated and analysed. Equations were generated to describe the changes in parameter values during growth. RESULTS Data on organ size show different growth patterns that were quantified as functions of bodyweight to retain physiological variability and correlation. Protein binding data were quantified as functions of age as the body weight was not reported in the original articles. Ontogeny functions were derived for cytochrome P450 1A2, 3A4 and 2C9. Tissue composition values and how they change with age are limited. CONCLUSIONS Despite the limitations identified in the availability of some tissue composition values, the data presented in this article provide an integrated resource of system parameters needed for building a preterm physiologically based pharmacokinetic model.
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Affiliation(s)
- Khaled Abduljalil
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK.
| | - Xian Pan
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Amita Pansari
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Masoud Jamei
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Trevor N Johnson
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
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10
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Population Pharmacokinetic Models of Vancomycin in Paediatric Patients: A Systematic Review. Clin Pharmacokinet 2021; 60:985-1001. [PMID: 34002357 DOI: 10.1007/s40262-021-01027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Vancomycin is commonly used to treat gram-positive bacterial infections in the paediatric population, but dosing can be challenging. Population pharmacokinetic (popPK) modelling can improve individualization of dosing regimens. The primary objective of this study was to describe popPK models of vancomycin and factors that influence pharmacokinetic (PK) variability in paediatric patients. METHODS Systematic searches were conducted in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, International Pharmaceutical Abstracts and the grey literature without language or publication status restrictions from inception to 17 August 2020. Observational studies that described the development of popPK models of vancomycin in paediatric patients (< 18 years of age) were included. Risk of bias was assessed using the National Heart, Lung and Blood Institute Study Quality Assessment Tool for Case Series Studies. RESULTS Sixty-four observational studies (1 randomized controlled trial, 13 prospective studies and 50 retrospective studies of 9019 patients with at least 25,769 serum vancomycin concentrations) were included. The mean age was 2.5 years (range 1 day-18 years), serum creatinine was 47.1 ± 33.6 µmol/L, and estimated creatinine clearance was 97.4 ± 76 mL/min/1.73m2. Most studies found that vancomycin PK was best described by a one-compartment model (71.9%). There was a wide range of clearance and volume of distribution (Vd) values (range 0.014-0.27 L/kg/h and 0.43-1.46 L/kg, respectively) with interindividual variability as high as 49.7% for clearance and 136% for Vd, proportional residual variability up to 37.5% and additive residual variability up to 17.5 mg/L. The most significant covariates for clearance were weight, age, and serum creatinine or creatinine clearance, and weight for Vd. Variable dosing recommendations were suggested. CONCLUSION Numerous popPK models of vancomycin were derived, however external validation of suggested dosing regimens and analyses in subgroup paediatric populations such as dialysis patients are still needed before a popPK model with best predictive performance can be applied for dosing recommendations. Significant intraindividual and interindividual PK variability was present, which demonstrated the need for ongoing therapeutic drug monitoring and derivation of PK models for vancomycin for certain subgroup populations, such as dialysis patients.
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van Groen BD, Pilla Reddy V, Badée J, Olivares‐Morales A, Johnson TN, Nicolaï J, Annaert P, Smits A, de Wildt SN, Knibbe CAJ, de Zwart L. Pediatric Pharmacokinetics and Dose Predictions: A Report of a Satellite Meeting to the 10th Juvenile Toxicity Symposium. Clin Transl Sci 2021; 14:29-35. [PMID: 32702198 PMCID: PMC7877839 DOI: 10.1111/cts.12843] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/14/2020] [Indexed: 12/13/2022] Open
Abstract
On April 24, 2019, a symposium on Pediatric Pharmacokinetics and Dose Predictions was held as a satellite meeting to the 10th Juvenile Toxicity Symposium. This symposium brought together scientists from academia, industry, and clinical research organizations with the aim to update each other on the current knowledge on pediatric drug development. Through more knowledge on specific ontogeny profiles of drug metabolism and transporter proteins, integrated into physiologically-based pharmacokinetic (PBPK) models, we have gained a more integrated understanding of age-related differences in pharmacokinetics (PKs), Relevant examples were presented during the meeting. PBPK may be considered the gold standard for pediatric PK prediction, but still it is important to know that simpler methods, such as allometry, allometry combined with maturation function, functions based on the elimination pathway, or linear models, also perform well, depending on the age range or the mechanisms involved. Knowledge from different methods and information sources should be combined (e.g., microdosing can reveal early read-out of age-related differences in exposure), and such results can be a value to verify models. To further establish best practices for dose setting in pediatrics, more in vitro and in vivo research is needed on aspects such as age-related changes in the exposure-response relationship and the impact of disease on PK. New information coupled with the refining of model-based drug development approaches will allow faster targeting of intended age groups and allow more efficient design of pediatric clinical trials.
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Affiliation(s)
- Bianca D. van Groen
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children’s HospitalRotterdamThe Netherlands
- Roche Pharma and Early Development (pRED)Roche Innovation Center BaselBaselSwitzerland
| | | | - Justine Badée
- Center for Pharmacometrics & Systems PharmacologyDepartment of PharmaceuticsUniversity of Florida at Lake NonaOrlandoFloridaUSA
- Modelling & SimulationNovartis Institutes for Biomedical ResearchBaselSwitzerland
| | | | | | - Johan Nicolaï
- Development ScienceUCB BioPharma SRLBraine‐l’AlleudBelgium
| | - Pieter Annaert
- Drug Delivery and DispositionKU Leuven Department of Pharmaceutical and Pharmacological SciencesLeuvenBelgium
| | - Anne Smits
- Neonatal Intensive Care UnitUniversity Hospitals LeuvenLeuvenBelgium
- Department of Development and RegenerationKU LeuvenLeuvenBelgium
| | - Saskia N. de Wildt
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children’s HospitalRotterdamThe Netherlands
- Department of Pharmacology and ToxicologyRadboud Institute for Health SciencesRadboud UniversityNijmegenThe Netherlands
| | - Catherijne A. J. Knibbe
- Systems Biomedicine and PharmacologyLeiden Academic Center for Drug ResearchLeiden UniversityLeidenThe Netherlands
- Department of Clinical PharmacySt. Antonius HospitalNieuwegeinThe Netherlands
| | - Loeckie de Zwart
- Drug Metabolism and PharmacokineticsJanssen R&D, a Division of Janssen Pharmaceutica NVBeerseBelgium
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Dao K, Guidi M, André P, Giannoni E, Basterrechea S, Zhao W, Fuchs A, Pfister M, Buclin T, Csajka C. Optimisation of vancomycin exposure in neonates based on the best level of evidence. Pharmacol Res 2020; 154:104278. [DOI: 10.1016/j.phrs.2019.104278] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 12/16/2022]
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Chung E, Lee SE, Abraham T, Saad NN, Gad A. Evaluation of vancomycin target trough attainment with published dosing regimens in the neonatal intensive care unit population. J Neonatal Perinatal Med 2019; 12:21-27. [PMID: 30149480 DOI: 10.3233/npm-182] [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] [Indexed: 01/19/2023]
Abstract
BACKGROUND Study aims to evaluate whether vancomycin dosing from published dosing algorithms correlate with the attainment of target troughs of 10 to 20 mg/L. METHODS NICU patients who received minimum three doses of vancomycin and had a trough level met inclusion criteria. Dosing information was retrospectively evaluated to determine which published dosing regimen was followed. Dosing algorithms used were matched to NeoFax/Harriet Lane, renal-function directed dosing, and weight-directed dosing, in which the latter two can be found in Pediatric and Neonatal Lexi-Drugs. Primary outcome was percentage of troughs within therapeutic (10 to 20 mg/L) and subtherapeutic (less than 10 mg/L) levels. RESULTS Of 97 troughs evaluated, NeoFax/Harriet Lane accounted for 86.6%, renal-function directed accounted for 5.1%, and weight-directed dosing accounted for 18.5% of dosing algorithms. NeoFax/Harriet Lane, renal-function directed, and weight-directed dosing attained therapeutic levels between 10 to 20 mg/L at a rate of 60.7%, 60%, and 50% of the time, respectively. With respect to initiation of therapy, a higher dose of 15 mg/kg versus 10 mg/kg attained therapeutic levels (p < 0.001; OR 11.22; 95% CI, 3.96 to 31.81), while a serum creatinine value below 0.5 mg/dL attained subtherapeutic levels (p = 0.028; OR 0.068; 95% CI, 0.006 to 0.74). CONCLUSIONS NeoFax, Harriet Lane, and renal-directed dosing from Pediatric and Neonatal Lexi-Drugs achieved target troughs within the 10 to 20 mg/L range more often than weight-directed dosing from Pediatric and Neonatal Lexi-Drugs. Initiating therapy at a higher dose and patient serum creatinine value above 0.5 mg/dL were factors significantly associated with a 10 to 20 mg/L range.
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Affiliation(s)
- E Chung
- Department of Pharmacy and Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, NY, USA
| | - S E Lee
- Department of Pharmacy and Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, NY, USA
| | - T Abraham
- Department of Pharmacy and Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, NY, USA
| | - N N Saad
- Department of Pharmacy and Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, NY, USA
| | - A Gad
- Department of Pharmacy and Department of Pediatrics, NewYork-Presbyterian Brooklyn Methodist Hospital, NY, USA
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Frymoyer A, Stockmann C, Hersh AL, Goswami S, Keizer RJ. Individualized Empiric Vancomycin Dosing in Neonates Using a Model-Based Approach. J Pediatric Infect Dis Soc 2019; 8:97-104. [PMID: 29294072 DOI: 10.1093/jpids/pix109] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/11/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Vancomycin dosing in neonates is challenging because of the large variation in pharmacokinetics. Existing empiric dosing recommendations use table-based formats, within which a neonate is categorized on the basis of underlying characteristics. The ability to individualize dosing is limited because of the small number of "dose categories," and achieving narrow exposure targets is difficult. Our objective was to evaluate a model-based dosing approach (which we designated Neo-Vanco) designed to individualize empiric vancomycin dosing in neonates. METHODS Neo-Vanco was developed on the basis of a published, externally validated population pharmacokinetic model. Using a simulation-based methodology, individualized empiric doses that maximize the probability of attaining a 24-hour area under the curve/minimum inhibitory concentration ratio (AUC24/MIC) of >400 while minimizing troughs >20 mg/L are calculated. To evaluate the Neo-Vanco strategy, retrospective data from neonates treated with vancomycin at 2 healthcare systems were used, and empiric dose recommendations from the following 4 sources were examined: Neo-Vanco, Neofax, Red Book, and Lexicomp. Predicted AUC24 and troughs were calculated and compared. RESULTS Overall, 492 neonates were evaluated (median postmenstrual age, 36 weeks [5th-95th percentiles (90% range), 25-47 weeks]; median weight, 2.4 kg [90% range, 0.6-4.8 kg]). The percentage of neonates predicted to achieve an AUC24/MIC of >400 was 94% with Neo-Vanco, 18% with Neofax, 23% with Red Book, and 55% with Lexicomp (all P < .0001 vs Neo-Vanco). Predicted troughs of >20 mg/L were infrequent and similar across the dosing approaches (Neo-Vanco, 2.8%; Neofax, 1.0% [P = .03]; Red Book, 2.6% [P = .99]; and Lexicomp, 4.1% [P = .27]. CONCLUSION A model-based dosing approach that individualizes empiric vancomycin dosing was predicted to improve achievement of target exposure levels in neonates. Prospective clinical evaluation is warranted.
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Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Chris Stockmann
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
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Pokorná P, Šíma M, Černá O, Allegaert K, Tibboel D, Slanař O. Actual body weight-based vancomycin dosing in neonates. J Chemother 2019; 31:307-312. [PMID: 30983533 DOI: 10.1080/1120009x.2019.1599574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Pavla Pokorná
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic.,Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic.,Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands
| | - Martin Šíma
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic
| | - Olga Černá
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands.,Department of development and regeneration , Katholieke Universiteit Leuven , Leuven , Belgium
| | - Dick Tibboel
- Department of Pediatrics - PICU/NICU, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Prague , Czech Republic.,Intensive Care and Department of Pediatric Surgery, Erasmus MC and Department of Neonatology- Sophia Childrens Hospital , Rotterdam , The Netherlands
| | - Ondřej Slanař
- Department of Pharmacology, General University Hospital, 1st Faculty of Medicine Charles University in Prague , Czech Republic , Prague , Czech Republic
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Al-Obaidy SSM, Halbus AF, Greenway GM, Paunov VN. Boosting the antimicrobial action of vancomycin formulated in shellac nanoparticles of dual-surface functionality. J Mater Chem B 2019. [DOI: 10.1039/c8tb03102a] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We demonstrate a strong enhancement of the antimicrobial action of vancomycin encapsulated in shellac nanocarriers with cationic surface functionality which concentrate on the microbial cell membranes.
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Affiliation(s)
- Saba S. M. Al-Obaidy
- Department of Chemistry and Biochemistry
- University of Hull
- Hull
- UK
- Department of Chemistry
| | - Ahmed F. Halbus
- Department of Chemistry and Biochemistry
- University of Hull
- Hull
- UK
- Department of Chemistry
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Radu L, Bengry T, Akierman A, Alshaikh B, Yusuf K, Dersch-Mills D. Evolution of empiric vancomycin dosing in a neonatal population. J Perinatol 2018; 38:1702-1707. [PMID: 30341404 DOI: 10.1038/s41372-018-0251-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 09/21/2018] [Accepted: 10/01/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 2014, we assessed the effectiveness of our neonatal vancomycin empirical dosing regimen (15-45 mg/kg/day) which led to development of a revised regimen (20-60 mg/kg/day). OBJECTIVE To validate the revised empirical vancomycin dosage regimen in achieving target troughs. METHODS The primary outcome of this multicenter retrospective before-and-after cohort study was the proportion of neonates in the present cohort achieving trough levels below, at or above target (<10, 10-20 and >20 mg/L). Secondary outcomes included difference between cohorts (historical and present) in mean troughs and proportion of patients achieving target levels. RESULTS Out of 118 participants, 63 (53.39%) achieved target troughs, 44 (37.29%) had below target troughs and 11 (9.32%) reached above target levels. Mean trough levels and proportion of patients achieving target levels were higher in the present versus historical cohort (p < 0.01 for all comparisons). CONCLUSIONS The revised empiric dosing regimen was more effective in achieving target serum trough concentrations.
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Affiliation(s)
- Luiza Radu
- Alberta Health Services, Pharmacy Services, Calgary, AB, Canada
| | - Tanner Bengry
- Alberta Health Services, Pharmacy Services, Calgary, AB, Canada
| | - Albert Akierman
- Division of Neonatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Belal Alshaikh
- Division of Neonatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Kamran Yusuf
- Division of Neonatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
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Gwee A, Cranswick N, Donath SM, Hunt R, Curtis N. Protocol for a randomised controlled trial of continuous infusions of vancomycin to improve the attainment of target vancomycin levels in young infants: The VANC trial. BMJ Open 2018; 8:e022603. [PMID: 30391914 PMCID: PMC6231575 DOI: 10.1136/bmjopen-2018-022603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Vancomycin is frequently used in the treatment of late-onset sepsis in young infants and is routinely administered as intermittent infusions (IIV); however, existing IIV dosing guidelines achieve target vancomycin levels in less than half of infants. Continuous infusions of vancomycin (CIV) are an attractive alternative as adult studies report a higher attainment of target vancomycin levels, simpler drug monitoring and fewer drug side effects. METHODS This is a multicentre, randomised controlled trial in which 200 young infants (aged 0-90 days) requiring vancomycin will be randomised to CIV or IIV for a duration determined by the treating clinician. Vancomycin levels will be measured immediately after the first dose in both arms. Trough and peak levels will be determined in the IIV arm and steady-state levels 18-30 hours after commencement of infusion will be measured in the CIV arm. Full blood count, urea and electrolytes, and C reactive protein level will be monitored throughout treatment. For all Gram-positive bacteria isolated from blood culture, a vancomycin Etest will be done to determine the minimum inhibitory concentration of the bacterium. ANALYSIS Primary outcome: the proportion of infants with levels within target range at their first steady-state concentration. SECONDARY OUTCOMES (1) the proportion of drug-related adverse effects; (2) the time to achieve target levels in the blood; (3) the pharmacodynamics of vancomycin (using non-linear mixed effect modelling). ETHICS AND DISSEMINATION The study has been approved by The Royal Children's Hospital Melbourne Human Research Ethics Committee (HREC) (No. 34030) and the South Eastern Sydney Local Health District HREC (SSA 16/G/335). Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02210169.
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Affiliation(s)
- Amanda Gwee
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Noel Cranswick
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Susan M Donath
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Rodney Hunt
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Nigel Curtis
- Departments of General Medicine and Neonatal Medicine, The Royal Children’s Hospital, Melbourne, Victoria, Australia
- Infectious Diseases & Microbiology, Neonatal Research, Clinical Epidemiology & Biostatistics Unit, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
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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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Factors impacting unbound vancomycin concentrations in neonates and young infants. Eur J Clin Microbiol Infect Dis 2018; 37:1503-1510. [DOI: 10.1007/s10096-018-3277-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/09/2018] [Indexed: 01/19/2023]
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Population Pharmacokinetics and Pharmacodynamic Target Attainment of Vancomycin in Neonates on Extracorporeal Life Support. Pediatr Crit Care Med 2017. [PMID: 28650363 DOI: 10.1097/pcc.0000000000001250] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To evaluate the population pharmacokinetics and pharmacodynamic target attainment of vancomycin in neonates with a contemporary ¼-inch extracorporeal life support circuit with a Quadrox-iD Pediatric oxygenator (Maquet Cardiovascular, LLC, Wayne, NJ). DESIGN Retrospective medical record review. SETTING Two free-standing tertiary/quaternary pediatric children's hospitals. PATIENTS Neonates receiving either veno-arterial or veno-venous extracorporeal life support and vancomycin for empiric or definitive therapy with resulting serum concentrations. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twelve patients with a median gestations age of 39 weeks (range 36-41 wk) and a median postnatal age of 9.5 days (range 0-28 d) accounted for 14 courses of vancomycin therapy while on extracorporeal life support and were included in the analysis. The median weight was 3.1 kg (range 2.2-4.41 kg) with five of 12 patients (41.7%) being female. Vancomycin concentrations were best described by an one-compartment model incorporating allometric scaling of estimated glomerular filtration rate on clearance. The mean total body clearance (mL/min/kg) for the population was 3.48 ± 1.31 mL/min/kg, and the mean total volume of distribution (L/kg) for the population was 1.2 ± 0.4 L/kg. The intermittent and continuous infusion dosing regimens that provided for the highest percentage of trough concentrations in the range of 10-20 mg/L were the 10 mg/kg/dose IV q8h, 12.5 mg/kg/dose IV q8-12h, 15 mg/kg/dose IV q12h, and 20 mg/kg/dose IV q12h, and the 20, 25, and 30 mg/kg/d continuous infusion regimens, respectively. All regimens allowed for an area under the concentration:minimum inhibitory concentration ratio of 400:1 for minimum inhibitory concentrations of less than or equal to 0.5 mg/L for a 90% PTA. None of the simulated regimens had a greater than 90% probability of achieving an area under the concentration:minimum inhibitory concentration ratio of 400:1 for vancomycin minimum inhibitory concentrations greater than or equal to 1 mg/L while maintaining trough concentrations in the range of 10-20 mg/L. CONCLUSIONS To our knowledge, this is the first pharmacokinetic and pharmacodynamic study of neonates receiving vancomycin with a contemporary ¼-inch extracorporeal life support circuit including the Quadrox-iD Pediatric oxygenator (Maquet Cardiovascular, LLC). The data suggest differences in vancomycin pharmacokinetics compared with previous extracorporeal life support data, notably a more rapid clearance, which could result in lower vancomycin concentrations. Considering this, a more aggressive initial dosing regimen may need to be employed in infants on extracorporeal life support.
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Different Vancomycin Immunoassays Contribute to the Variability in Vancomycin Trough Measurements in Neonates. BIOMED RESEARCH INTERNATIONAL 2016; 2016:1974972. [PMID: 27635396 PMCID: PMC5011197 DOI: 10.1155/2016/1974972] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 07/31/2016] [Indexed: 11/26/2022]
Abstract
Substantial interassay variability (up to 20%) has been described for vancomycin immunoassays in adults, but the impact of neonatal matrix is difficult to quantify because of blood volume constraints in neonates. However, we provide circumstantial evidence for a similar extent of variability. Using the same vancomycin dosing regimens and confirming similarity in clinical characteristics, vancomycin trough concentrations measured by PETINIA (2011-2012, n = 400) were 20% lower and the mean difference was 1.93 mg/L compared to COBAS (2012–2014, n = 352) measurements. The impact of vancomycin immunoassays in neonatal matrix was hereby suggested, supporting a switch to more advanced techniques (LC-MS/MS).
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Constance JE, Balch AH, Stockmann C, Linakis MW, Korgenski EK, Roberts JK, Ward RM, Sherwin CMT, Spigarelli MG. A propensity-matched cohort study of vancomycin-associated nephrotoxicity in neonates. Arch Dis Child Fetal Neonatal Ed 2016; 101:F236-43. [PMID: 26400103 DOI: 10.1136/archdischild-2015-308459] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 09/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND The incidence of nephrotoxicity among vancomycin-treated neonates has been reported to range from 2% to 20%. These widely varying estimates have led to confusion and controversy regarding the safety of vancomycin among neonates. OBJECTIVE Evaluate the incidence of nephrotoxicity among neonates receiving vancomycin concomitantly with gentamicin. DESIGN Retrospective observational cohort study using propensity score matching to provide covariate balance between neonates who did or did not receive vancomycin based on factors known to be related to the development of renal dysfunction. SETTING Hospitals (n=22) throughout the Intermountain West, including a quaternary care children's hospital. PATIENTS Neonates ≤44 postmenstrual weeks (median gestational age: 31 (IQR 28-36) weeks) receiving intravenous gentamicin with or without exposure to vancomycin from January 2006 to December 2012. MAIN OUTCOME MEASURES Nephrotoxicity based on the modified Acute Kidney Injury Network criteria for acute kidney injury (AKI) or serum creatinine concentration ≥1.5 mg/dL persisting for ≥48 h. RESULTS The final cohort was comprised of 1066 neonates (533 receiving vancomycin and gentamicin vs 533 receiving gentamicin). In a propensity score-matched cohort that was well balanced across 16 covariates, AKI was not associated with vancomycin use (16 neonates receiving vancomycin vs 7 controls experienced AKI; OR 1.5; 95% CI 0.6 to 4.0). However, the presence of a patent ductus arteriosus, concomitant non-steroidal anti-inflammatory drug use, ≥1 positive blood cultures, low birth weight and higher severity of illness and risk of mortality scores were associated with an increased risk of nephrotoxicity. CONCLUSIONS These results corroborate several earlier reports and much anecdotal evidence describing the infrequent occurrence of nephrotoxicity in neonates receiving concomitant vancomycin and gentamicin.
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Affiliation(s)
| | - Alfred H Balch
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Chris Stockmann
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Matthew W Linakis
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - E Kent Korgenski
- Pediatric Clinical Program, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Jessica K Roberts
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Robert M Ward
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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25
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Vancomycin dosing nomograms targeting high serum trough levels in different populations: pros and cons. Eur J Clin Pharmacol 2016; 72:777-88. [PMID: 27117446 DOI: 10.1007/s00228-016-2063-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
PURPOSE Utilization of higher doses of vancomycin to achieve the trough concentrations of 15-20 mg/L for complicated infections has been recommended by the Infectious Diseases Society of America clinical practice guideline in recent years. Concerning this recommendation, several nomograms have been constructed targeting this optimal trough level range in different populations of patients. In this review, we have collected available nomograms targeting high trough serum levels of vancomycin, particularly comparing their advantages and limitations. METHOD The data were collected by searching Scopus, PubMed, Google scholar, Medline, and Cochrane database systematic reviews. The key words used as search terms were "vancomycin", "high trough level", "dosing nomogram", "dosing strategy", "neonates", "critically ill", "pediatrics", and "hemodialysis". We have included 17 related human studies published up to the date of this publication. RESULTS & CONCLUSION Most of the available nomograms have determined the doses according to body weight and renal function. Their initial predicting success rate were 44-76 % for non-critically ill patients, 42-84 % for critically ill patients, 54 % for one nomogram specially designed for hemodialysis patients, and 71 % for the only nomogram developed for neonates. Based on validation studies, in most of cases, using a vancomycin dosing nomogram significantly improved and accelerated achievement of target trough concentrations. However, it should be noted that there are limited data about patients' clinical and microbiological outcomes and they are only validated in narrow groups of patients. Thus, their widespread application could not be encouraged for all patients before performing adequately powered, prospective randomized studies.
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26
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Wilbaux M, Fuchs A, Samardzic J, Rodieux F, Csajka C, Allegaert K, van den Anker JN, Pfister M. Pharmacometric Approaches to Personalize Use of Primarily Renally Eliminated Antibiotics in Preterm and Term Neonates. J Clin Pharmacol 2016; 56:909-35. [PMID: 26766774 DOI: 10.1002/jcph.705] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 12/13/2022]
Abstract
Sepsis remains a major cause of mortality and morbidity in neonates, and, as a consequence, antibiotics are the most frequently prescribed drugs in this vulnerable patient population. Growth and dynamic maturation processes during the first weeks of life result in large inter- and intrasubject variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics. In this review we (1) summarize the available population PK data and models for primarily renally eliminated antibiotics, (2) discuss quantitative approaches to account for effects of growth and maturation processes on drug exposure and response, (3) evaluate current dose recommendations, and (4) identify opportunities to further optimize and personalize dosing strategies of these antibiotics in preterm and term neonates. Although population PK models have been developed for several of these drugs, exposure-response relationships of primarily renally eliminated antibiotics in these fragile infants are not well understood, monitoring strategies remain inconsistent, and consensus on optimal, personalized dosing of these drugs in these patients is absent. Tailored PK/PD studies and models are useful to better understand relationships between drug exposures and microbiological or clinical outcomes. Pharmacometric modeling and simulation approaches facilitate quantitative evaluation and optimization of treatment strategies. National and international collaborations and platforms are essential to standardize and harmonize not only studies and models but also monitoring and dosing strategies. Simple bedside decision tools assist clinical pharmacologists and neonatologists in their efforts to fine-tune and personalize the use of primarily renally eliminated antibiotics in term and preterm neonates.
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Affiliation(s)
- Mélanie Wilbaux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Aline Fuchs
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Janko Samardzic
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Frédérique Rodieux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Chantal Csajka
- Division of Clinical Pharmacology, Service of Biomedicine, Department of Laboratory, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Belgium.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johannes N van den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Marc Pfister
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Quantitative Solutions LP, Menlo Park, CA, USA
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27
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Samardzic J, Allegaert K, Wilbaux M, Pfister M, van den Anker JN. Quantitative clinical pharmacology practice for optimal use of antibiotics during the neonatal period. Expert Opin Drug Metab Toxicol 2016; 12:367-75. [PMID: 26817821 DOI: 10.1517/17425255.2016.1147559] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION For safe and effective neonatal antibiotic therapy, knowledge of the pharmacokinetic parameters of antibacterial agents in neonates is a prerequisite. Fast maturational changes during the neonatal period influence pharmacokinetic and pharmacodynamic parameters and their variability. Consequently, the need for applying quantitative clinical pharmacology and determining optimal drug dosing regimens in neonates has become increasingly recognized. AREAS COVERED Modern quantitative approaches, such as pharmacometrics, are increasingly utilized to characterize, understand and predict the pharmacokinetics of a drug and its effect, and to quantify the variability in the neonatal population. Individual factors, called covariates in modeling, are integrated in such approaches to explain inter-individual pharmacokinetic variability. Pharmacometrics has been shown to be a relevant tool to evaluate, optimize and individualize drug dosing regimens. EXPERT OPINION Challenges for optimal use of antibiotics in neonates can largely be overcome with quantitative clinical pharmacology practice. Clinicians should be aware that there is a next step to support the clinical decision-making based on clinical characteristics and therapeutic drug monitoring, through Bayesian-based modeling and simulation methods. Pharmacometric modeling and simulation approaches permit us to characterize population average, inter-subject and intra-subject variability of pharmacokinetic parameters such as clearance and volume of distribution, and to identify and quantify key factors that influence the pharmacokinetic behavior of antibiotics during the neonatal period.
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Affiliation(s)
- Janko Samardzic
- a Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty , University of Belgrade , Belgrade , Serbia.,b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Karel Allegaert
- c Department of Development and Regeneration , KU Leuven , Leuven , Belgium.,d Intensive Care and Department of Pediatric Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Mélanie Wilbaux
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Marc Pfister
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - John N van den Anker
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,d Intensive Care and Department of Pediatric Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , the Netherlands.,e Division of Pediatric Clinical Pharmacology , Children's National Medical Center , Washington , DC , USA
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Towards Rational Dosing Algorithms for Vancomycin in Neonates and Infants Based on Population Pharmacokinetic Modeling. Antimicrob Agents Chemother 2015; 60:1013-21. [PMID: 26643337 DOI: 10.1128/aac.01968-15] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/22/2015] [Indexed: 01/08/2023] Open
Abstract
Because of the recent awareness that vancomycin doses should aim to meet a target area under the concentration-time curve (AUC) instead of trough concentrations, more aggressive dosing regimens are warranted also in the pediatric population. In this study, both neonatal and pediatric pharmacokinetic models for vancomycin were externally evaluated and subsequently used to derive model-based dosing algorithms for neonates, infants, and children. For the external validation, predictions from previously published pharmacokinetic models were compared to new data. Simulations were performed in order to evaluate current dosing regimens and to propose a model-based dosing algorithm. The AUC/MIC over 24 h (AUC24/MIC) was evaluated for all investigated dosing schedules (target of >400), without any concentration exceeding 40 mg/liter. Both the neonatal and pediatric models of vancomycin performed well in the external data sets, resulting in concentrations that were predicted correctly and without bias. For neonates, a dosing algorithm based on body weight at birth and postnatal age is proposed, with daily doses divided over three to four doses. For infants aged <1 year, doses between 32 and 60 mg/kg/day over four doses are proposed, while above 1 year of age, 60 mg/kg/day seems appropriate. As the time to reach steady-state concentrations varies from 155 h in preterm infants to 36 h in children aged >1 year, an initial loading dose is proposed. Based on the externally validated neonatal and pediatric vancomycin models, novel dosing algorithms are proposed for neonates and children aged <1 year. For children aged 1 year and older, the currently advised maintenance dose of 60 mg/kg/day seems appropriate.
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Predictive Performance of a Vancomycin Population Pharmacokinetic Model in Neonates. Infect Dis Ther 2015; 4:187-98. [PMID: 25998107 PMCID: PMC4471056 DOI: 10.1007/s40121-015-0067-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION The pharmacokinetics of vancomycin are highly variable among neonates, which makes dosing challenging in this population. However, adequate drug exposure is critical, especially when treating methicillin-resistant Staphylococcus aureus (MRSA) infections. Utilization of population pharmacokinetic models and Bayesian methods offers the potential for developing individualized therapeutic approaches. To meet this need, a neonatal vancomycin population pharmacokinetic model was recently published. The current study sought to externally evaluate the predictive performance and generalizability of this model. METHODS A retrospective chart review of neonates who received vancomycin and had ≥1 peak and ≥1 trough concentrations at five Intermountain Healthcare neonatal intensive care units from 2006 to 2013 was performed and served as the external validation cohort. The published population pharmacokinetic model was implemented in NONMEM 7.2 with the structural and variance parameter values set equal to the estimates reported previously. The model was then used to predict the first peak and trough concentration for each neonate in the validation cohort and the model prediction error and absolute prediction error were calculated. Normalized prediction distribution errors (NPDE) were also evaluated. RESULTS A total of 243 neonates were studied with a median postmenstrual age of 33 (range: 23-54) weeks and a median weight of 1.6 (range: 0.4-6.8) kg. The model predicted the observed vancomycin concentrations with reasonable precision. For all vancomycin concentrations, the median prediction error was -0.8 (95% CI: -1.4 to -0.4) mg/L and the median absolute prediction error was 3.0 (95% CI: 2.7-3.5) mg/L. No trends in NPDE across weight, postmenstrual age, serum creatinine, or time after dose were observed. CONCLUSION An evaluation of a recently published neonatal vancomycin population pharmacokinetic model in a large external dataset supported the predictive performance and generalizability of the model. This model may be useful in evaluating neonatal vancomycin dosing regimens and estimating the extent of drug exposure.
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30
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Petrie K, O'Brien C, Bhushan S, Tonna A. Neonatal vancomycin trough level audit using British National Formulary for Children dosing. Arch Dis Child Fetal Neonatal Ed 2015; 100:F278-9. [PMID: 25519438 DOI: 10.1136/archdischild-2014-307725] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2014] [Indexed: 11/03/2022]
Affiliation(s)
- Kate Petrie
- Pharmacy Department, Ninewells Hospital, Dundee, UK
| | | | | | - Antonella Tonna
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
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