1
|
Wei XC, Zhao MF, Xiao X. Assessment of micafungin dosage regimens against Candida spp. in pediatric patients undergoing hematopoietic stem cell transplantation: a pharmacokinetic/pharmacodynamic analysis using Monte Carlo simulation. J Chemother 2023; 35:721-729. [PMID: 37190751 DOI: 10.1080/1120009x.2023.2212986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 03/21/2023] [Accepted: 04/21/2023] [Indexed: 05/17/2023]
Abstract
The objective of this study was to evaluate the efficacy of various micafungin dosing regimens against Candida spp. in pediatric patients undergoing hematopoietic stem cell transplantation (HSCT). Monte Carlo simulations were conducted using pharmacokinetic (PK) parameters and pharmacodynamic (PD) data to determine the probabilities of target attainment and cumulative fractions of response in terms of area under the concentration curve/minimum inhibition concentration targets of micafungin. Current standard clinical micafungin dosing regimens of 1 and 2 mg/kg/day were appropriate for the prevention and treatment of Candida glabrata infection in pediatric patients undergoing HSCT, respectively. Moreover, the high-dose prophylactic dosage (2 mg/kg/day) and therapeutic dosage (4 mg/kg/day) should be the preferred option to optimize efficacy against Candida albicans. However, none of the simulated regimens was effective against Candida parapsilosis in pediatric HSCT patients. These PK/PD-based simulations rationalize and optimize the micafungin dosing regimens against Candida spp. in pediatric patients undergoing HSCT.
Collapse
Affiliation(s)
- Xiao-Chen Wei
- Department of Pharmacy, Tianjin First Central Hospital, Tianjin, PR China
| | - Ming-Feng Zhao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, PR China
| | - Xia Xiao
- Department of Hematology, Tianjin First Central Hospital, Tianjin, PR China
| |
Collapse
|
2
|
Kim HY, Baldelli S, Märtson AG, Stocker S, Alffenaar JW, Cattaneo D, Marriott DJE. Therapeutic Drug Monitoring of the Echinocandin Antifungal Agents: Is There a Role in Clinical Practice? A Position Statement of the Anti-Infective Drugs Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit 2022; 44:198-214. [PMID: 34654030 DOI: 10.1097/ftd.0000000000000931] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Reduced exposure to echinocandins has been reported in specific patient populations, such as critically ill patients; however, fixed dosing strategies are still used. The present review examines the accumulated evidence supporting echinocandin therapeutic drug monitoring (TDM) and summarizes available assays and sampling strategies. METHODS A literature search was conducted using PubMed in December 2020, with search terms such as echinocandins, anidulafungin, caspofungin, micafungin, or rezafungin with pharmacology, pharmacokinetics (PKs), pharmacodynamics (PDs), drug-drug interactions, TDM, resistance, drug susceptibility testing, toxicity, adverse drug reactions, bioanalysis, chromatography, and mass spectrometry. Data on PD/PD (PK/PD) outcome markers, drug resistance, PK variability, drug-drug interactions, assays, and TDM sampling strategies were summarized. RESULTS Echinocandins demonstrate drug exposure-efficacy relationships, and maximum concentration/minimal inhibitory concentration ratio (Cmax/MIC) and area under the concentration-time curve/MIC ratio (AUC/MIC) are proposed PK/PD markers for clinical response. The relationship between drug exposure and toxicity remains poorly clarified. TDM could be valuable in patients at risk of low drug exposure, such as those with critical illness and/or obesity. TDM of echinocandins may also be useful in patients with moderate liver impairment, drug-drug interactions, hypoalbuminemia, and those undergoing extracorporeal membrane oxygenation, as these conditions are associated with altered exposure to caspofungin and/or micafungin. Assays are available to measure anidulafungin, micafungin, and caspofungin concentrations. A limited-sampling strategy for anidulafungin has been reported. CONCLUSIONS Echinocandin TDM should be considered in patients at known risk of suboptimal drug exposure. However, for implementing TDM, clinical validation of PK/PD targets is needed.
Collapse
Affiliation(s)
- Hannah Yejin Kim
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Sara Baldelli
- Unit of Clinical Pharmacology, Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sophie Stocker
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Kensington, NSW Australia; and
| | - Jan-Willem Alffenaar
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
- Westmead Hospital, Westmead, NSW, Australia
- Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Camperdown, NSW, Australia
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Fatebenefratelli Sacco University Hospital, Milan, Italy
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Deborah J E Marriott
- St Vincent's Clinical School, University of New South Wales, Kensington, NSW Australia; and
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| |
Collapse
|
3
|
Ekinci F, Yildizdas D, Horoz OO, Ozgur Gundeslioglu O, Alabaz D. Treatment of Candida urinary tract infections with micafungin in children. Pediatr Int 2022; 64:e15033. [PMID: 35146837 DOI: 10.1111/ped.15033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/30/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Candida urinary tract infections (UTIs) are common nosocomial infections among critically ill patients hospitalized in pediatric intensive care Units (PICU). We aimed to report outcomes of critically ill pediatric patients who received micafungin for hospital acquired Candida UTIs. We analyzed treatment success rates and success rates among different Candida species. METHODS This retrospective cohort study included patients who received micafungin for Candida UTI as first choice in our PICU between January 2017 and July 2018. Data, including demographic and clinical features, were retrospectively collected from medical files of the patients. Treatment efficacy was defined as resolution of clinical symptoms and a negative culture for Candida at day 14 after initiation of micafungin treatment. RESULTS Twenty-four pediatric patients (median age 5.72 years, range, 2 months-16 years) were included in the present study. Fourteen (58.3%) patients had urinary catheters at the time of Candida isolation. Resolution of symptoms and a negative culture at day 3 of micafungin treatment were achieved in 17 (70.8%) and 14 (58.3%) patients, respectively. Moreover, 19 (79.2%) patients had a normal urine analysis and negative culture 14 days after initiation of micafungin treatment. Treatment responses did not statistically differ between Candida species. CONCLUSIONS Micafungin is safe and efficacious in critically ill pediatric patients with Candida UTIs. Its efficacy in our pediatric population was as comparable to that observed in adult studies, therefore, it should be considered as an effective therapeutic option in Candida UTIs of critically ill pediatric patients.
Collapse
Affiliation(s)
- Faruk Ekinci
- Department of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Ozden Ozgur Horoz
- Department of Pediatric Intensive Care, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Ozlem Ozgur Gundeslioglu
- Department of Pediatric Infectious Diseases, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Derya Alabaz
- Department of Pediatric Infectious Diseases, Çukurova University Faculty of Medicine, Adana, Turkey
| |
Collapse
|
4
|
Li F, Zhou M, Jiao Z, Zou Z, Yu E, He Z. Caspofungin pharmacokinetics and probability of target attainment in ICU patients in China. J Glob Antimicrob Resist 2021; 25:238-263. [PMID: 33845162 DOI: 10.1016/j.jgar.2021.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/18/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Effective antifungal therapy is important to reduce mortality in patients with invasive fungal infections (IFIs). Numerous factors affect pharmacokinetic/pharmacodynamic (PK/PD) parameters in critically-ill patients. To guide individualised administration in critically-ill patients, it is of great significance to determine the population pharmacokinetics of caspofungin. METHODS A prospective study in 42 ICU patients with IFIs was conducted in China. A population pharmacokinetic model of caspofungin was established using a non-linear mixed-effects model, which was utilised to investigate the effects of demographic indices, liver function and kidney function on pharmacokinetics. Additionally, appropriate dosages of caspofungin under various scenarios were determined based on MICs and probability of target attainment (PTA) at specific dosages. RESULTS In critically-ill Chinese patients, clearance (CL), volume of distribution (V) and area under the curve at steady-state (AUCss) of caspofungin were 0.32 L/h, 6.77 L and 135.47 mg•h/L, respectively. Blood albumin and total bilirubin levels were factors affecting CL, while body weight was the only factor affecting V among Chinese people with relatively low weight compared with other populations. A maintenance dose of 50 mg caspofungin achieved a high PTA for treating IFIs caused by Candida albicans (MIC ≤ 0.06 mg/L) and Candida glabrata (MIC ≤ 0.125 mg/L). The maintenance dose of caspofungin should be adjusted to 70-200 mg for IFIs caused by C. albicans (MIC, 0.06-0.125 mg/L). For IFIs caused by Candida parapsilosis, an MIC > 0.03 mg/L is associated with a very low PTA, but higher doses of caspofungin or alternative antifungals need to be further studied. CONCLUSION The population pharmacokinetic model established here described well the PK/PD characteristics of caspofungin in critically-ill Chinese patients. These results could guide the formulation of individualised caspofungin dosing regimens for critically-ill patients.
Collapse
Affiliation(s)
- Fangyi Li
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China
| | - Minggen Zhou
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China; Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China.
| | - Zijun Zou
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China
| | - Erqian Yu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China; The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhijie He
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan Jiang West Road, Guangzhou 510120, Guangdong, China.
| |
Collapse
|
5
|
Chen YH, Cheng IL, Lai CC, Tang HJ. Echinocandins vs. amphotericin B against invasive candidiasis in children and neonates: A meta-analysis of randomized controlled trials. Int J Antimicrob Agents 2019; 53:789-794. [PMID: 30831231 DOI: 10.1016/j.ijantimicag.2019.02.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 01/10/2019] [Accepted: 02/26/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this meta-analysis was to assess the efficacy and safety of treatment with echinocandins compared with amphotericin B in paediatric patients with invasive candidiasis. METHODS PubMed, Embase and Cochrane databases were searched up to August 2018. Only randomized controlled trials (RCTs) evaluating echinocandins and amphotericin B in the treatment of paediatric patients with invasive candidiasis were included. The outcomes were clinical responses and adverse effects. RESULTS Five RCTs of 354 patients (191 patients in the echinocandins group and 163 patients in the amphotericin B group) were included in this study. Overall, no significant differences in clinical response were found between echinocandins and amphotericin B (odds ratio [OR], 1.38; 95% confidence interval [CI], 0.68-2.80; I2 = 39%). Similar results were also observed in the high-risk group (OR, 3.10; 95% CI, 0.10-97.23; I2 = 76%), the low-risk group (OR, 1.29; 95% CI, 0.36-4.62; I2 = 21%) and the neutropenia group (OR, 1.56; 95% CI, 0.75-3.26; I2 = 0%). The risk of discontinuing treatment because of adverse effects was significantly lower in the echinocandins group than in the amphotericin B group (OR, 0.30, 95% CI, 0.12-0.76; I2 = 0%). CONCLUSIONS There were no differences in efficacy between the echinocandins group and the amphotericin B group in the treatment of invasive candidiasis in paediatric patients. However, the echinocandins group had a significantly lower risk of discontinuing treatment than the amphotericin B group.
Collapse
Affiliation(s)
- Yu-Hung Chen
- Department of Pharmacy, Chi Mei Medical Center, Liouying, Taiwan
| | - I-Ling Cheng
- Department of Pharmacy, Chi Mei Medical Center, Liouying, Taiwan
| | - Chih-Cheng Lai
- Intensive Care Medicine, Chi Mei Medical Center, Liouying, Taiwan
| | - Hung-Jen Tang
- Department of Medicine, Chi Mei Medical Center, Tainan, Taiwan.
| |
Collapse
|
6
|
Low penetration of caspofungin into cerebrospinal fluid following intravenous administration of standard doses. Int J Antimicrob Agents 2017; 50:272-275. [DOI: 10.1016/j.ijantimicag.2017.02.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/07/2017] [Accepted: 02/22/2017] [Indexed: 01/05/2023]
|
7
|
Pérez-Pitarch A, Ferriols-Lisart R, Aguilar G, Ezquer-Garín C, Belda FJ, Guglieri-López B. Dosing of caspofungin based on a pharmacokinetic/pharmacodynamic index for the treatment of invasive fungal infections in critically ill patients on continuous venovenous haemodiafiltration. Int J Antimicrob Agents 2017; 51:115-121. [PMID: 28666752 DOI: 10.1016/j.ijantimicag.2017.05.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/10/2017] [Accepted: 05/01/2017] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The study objective was to evaluate the efficacy of different dosages of caspofungin in the treatment of invasive candidiasis and aspergillosis, in relation to the probability of pharmacokinetic/pharmacodynamic (PK/PD) target attainment, using modelling and Monte Carlo simulations in critically ill adult patients on continuous haemodiafiltration. METHODS Critically ill adult patients on continuous venovenous haemodiafiltration treated with caspofungin were analysed. A population PK model was developed. Four caspofungin dosing regimens were simulated: the licensed regimen, 70 mg/day, 100 mg/day or 200 mg/day. A PK/PD target was defined as the ratio between the area under the caspofungin concentration-time curve over 24 hours and the minimal inhibitory concentration (AUC/MIC) for candidiasis or the minimal effective concentrations (AUC/MEC) for Aspergillus spp. Target attainment based on preclinical target for Candida and Aspergillus was assessed for different MIC or MEC, respectively. RESULTS Concentration-time data were described by a two-compartment model. Body-weight and protein concentration were the only covariates identified by the model. Goodness-of-fit plots and bootstrap analysis proved the model had a satisfactory performance. As expected, a higher maintenance dose resulted in a higher exposure. Target attainment was >90% for candidiasis (MIC≤0.06 mg/L) and aspergillosis (MEC≤0.5 mg/L), irrespective of the dosing regimen, but not for C. parapsilosis. Standard regimen was insufficient to reach the target for C. albicans and C. parapsilosis with MIC≥0.1 mg/L. CONCLUSION The licensed regimen of caspofungin is insufficient to achieve the PK/PD targets in critically ill patients on haemodiafiltration. The determination of MICs will enable dose scheme selection.
Collapse
Affiliation(s)
- Alejandro Pérez-Pitarch
- Department of Pharmacy, University Clinical Hospital of Valencia, Valencia, Spain; Pharmacy and Pharmaceutical Technology Department, Pharmacy School, University of Valencia, Valencia, Spain.
| | | | - Gerardo Aguilar
- Surgical Intensive Care Unit, Department of Anaesthesiology and Intensive Care, Hospital Clínico Universitario, Valencia, Spain
| | - Carlos Ezquer-Garín
- Health Research Institute, INCLIVA, Avenida Blasco Ibáñez, 17, 46010 Valencia, Spain
| | - F Javier Belda
- Surgical Intensive Care Unit, Department of Anaesthesiology and Intensive Care, Hospital Clínico Universitario, Valencia, Spain; School of Medicine, University of Valencia, Spain
| | - Beatriz Guglieri-López
- Pharmacy and Pharmaceutical Technology Department, Pharmacy School, University of Valencia, Valencia, Spain
| |
Collapse
|
8
|
Yang Q, Wang T, Xie J, Wang Y, Zheng X, Chen L, Li Y, Meng T, Dong Y. Pharmacokinetic/pharmacodynamic adequacy of echinocandins against Candida spp. in intensive care unit patients and general patient populations. Int J Antimicrob Agents 2016; 47:397-402. [PMID: 27068676 DOI: 10.1016/j.ijantimicag.2016.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/01/2016] [Accepted: 02/14/2016] [Indexed: 11/18/2022]
Abstract
This study evaluated whether contemporary echinocandin regimens achieved pharmacokinetic/pharmacodynamic targets in ICU patients and general patient populations (GPPs) and assessed caspofungin (CAS) regimens in hepatic impairment (HI) patients. A Monte Carlo simulation was performed using previously published data. Recommended dosing regimens of echinocandins in ICU patients, GPPs and healthy volunteers were evaluated: 70mg loading dose then 50mg maintenance dose (70/50mg) for CAS; 100mg q24h for micafungin (MCF); and 200/100mg for anidulafungin (ANF). Moreover, CAS 70mg and 100mg q24h in GPPs, and CAS 70/50mg and 70/35mg in mild and moderate HI patients, respectively, were evaluated. Cumulative fraction of response (CFR) was calculated for each dosing regimen. For Candida albicans, CFRs for the recommended doses of CAS, MCF and ANF were 95.8%, 13.5% and 50.5% in ICU patients and 96.3%, 42.4% and 61.6% in GPPs, respectively; for Candida glabrata, CFRs were 99.4%, 90.6% and 44.6% in ICU patients and 99.5%, 97.1% and 59.8% in GPPs. For Candida parapsilosis, CFRs of echinocandins for standard regimens were <70%; only CAS 100mg q24h achieved the target CFR. CAS 70/50mg and 70/35mg in mild and moderate HI patients were appropriate. Considerable interindividual variability was observed. For C. albicans and C. glabrata, CAS is good choice both for ICU and other patient populations, but for C. parapsilosis an increased dose should be considered. For MCF and ANF, administering higher doses with longer dosing intervals achieves better target attainment and should be investigated in clinical trials.
Collapse
Affiliation(s)
- Qianting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Jiao Xie
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Yan Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Xiaowei Zheng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Lu Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Ying Li
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Ti Meng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, China.
| |
Collapse
|