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Duong A, Marsot A. Nlmixr2 Versus NONMEM: An Evaluation of Maximum A Posteriori Bayesian Estimates Following External Evaluation of Gentamicin and Tobramycin Population Pharmacokinetic Models. Clin Pharmacol Drug Dev 2024; 13:739-747. [PMID: 38465725 DOI: 10.1002/cpdd.1395] [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: 11/11/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024]
Abstract
The objective of this project is to compare the results of the same study carried out on NONMEM and nlmixr2. This analysis consists of evaluating previously published population pharmacokinetic models of gentamicin and tobramycin in our population of interest with sparse concentrations. A literature review was performed to determine the gentamicin and tobramycin models in critically ill adult patients. In parallel, gentamicin and tobramycin dosing data, information on the treatment, the patient, and the bacteria were collected retrospectively in 2 Quebec establishments. The external evaluations were previously performed using NONMEM Version 7.5. Model equations were rewritten with R, and external evaluations were performed using nlmixr2. Predictive performance was assessed based on the estimation of bias and imprecision of the prediction error for maximum a posteriori (MAP) Bayesian PK parameter and observed concentrations. Comparison between nlmixr2 and NONMEM was performed on 4 gentamicin and 3 tobramycin population pharmacokinetic models. Compared to NONMEM, for gentamicin and tobramycin clearance and central volume of distribution, nlmixr2 produced individual pharmacokinetic parameters with bias values ranging from -32.5% to 5.67% and imprecision values ranging from 6.33% to 32.5%. Despite these differences, population bias and imprecision for sparse concentrations were low and ranged from 0% to 5.3% and 0.2% to 6.5%, respectively. The external evaluations performed with both software packages resulted in the same interpretation in terms of population predictive performance for all 7 models. Nlmxir2 showed comparable predictive performance with NONMEM with sparse concentrations that are, at most, sampled twice within a single dose administration (peak and trough).
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Affiliation(s)
- Alexandre Duong
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Montréal, QC, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada
| | - Amélie Marsot
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Montréal, QC, Canada
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada
- Centre de Recherche CHU Sainte-Justine, Montréal, QC, Canada
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2
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Verrest L, Roseboom IC, Wasunna M, Mbui J, Njenga S, Musa AM, Olobo J, Mohammed R, Ritmeijer K, Chu WY, Huitema ADR, Solomos A, Alves F, Dorlo TPC. Population pharmacokinetics of a combination of miltefosine and paromomycin in Eastern African children and adults with visceral leishmaniasis. J Antimicrob Chemother 2023; 78:2702-2714. [PMID: 37726401 PMCID: PMC10631828 DOI: 10.1093/jac/dkad286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES To improve visceral leishmaniasis (VL) treatment in Eastern Africa, 14- and 28-day combination regimens of paromomycin plus allometrically dosed miltefosine were evaluated. As the majority of patients affected by VL are children, adequate paediatric exposure to miltefosine and paromomycin is key to ensuring good treatment response. METHODS Pharmacokinetic data were collected in a multicentre randomized controlled trial in VL patients from Kenya, Sudan, Ethiopia and Uganda. Patients received paromomycin (20 mg/kg/day for 14 days) plus miltefosine (allometric dose for 14 or 28 days). Population pharmacokinetic models were developed. Adequacy of exposure and target attainment of paromomycin and miltefosine were evaluated in children and adults. RESULTS Data from 265 patients (59% ≤12 years) were available for this pharmacokinetic analysis. Paromomycin exposure was lower in paediatric patients compared with adults [median (IQR) end-of-treatment AUC0-24h 187 (162-203) and 242 (217-328) µg·h/mL, respectively], but were both within the IQR of end-of-treatment exposure in Kenyan and Sudanese adult patients from a previous study. Cumulative miltefosine end-of-treatment exposure in paediatric patients and adults [AUCD0-28 517 (464-552) and 524 (456-567) µg·day/mL, respectively] and target attainment [time above the in vitro susceptibility value EC90 27 (25-28) and 30 (28-32) days, respectively] were comparable to previously observed values in adults. CONCLUSIONS Paromomycin and miltefosine exposure in this new combination regimen corresponded to the desirable levels of exposure, supporting the implementation of the shortened 14 day combination regimen. Moreover, the lack of a clear exposure-response and exposure-toxicity relationship indicated adequate exposure within the therapeutic range in the studied population, including paediatric patients.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ignace C Roseboom
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Simon Njenga
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Joseph Olobo
- Department of Immunology and Molecular Biology, Makerere University, Kampala, Uganda
| | - Rezika Mohammed
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | | | - Wan-Yu Chu
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Fabiana Alves
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Kato H, Hagihara M, Matsuda H, Iwamoto T. Gentamicin Pharmacokinetics and Optimal Dosage in Infant Patients: A Case Report and Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15360. [PMID: 36430078 PMCID: PMC9691146 DOI: 10.3390/ijerph192215360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/08/2022] [Accepted: 11/18/2022] [Indexed: 06/16/2023]
Abstract
Gentamicin is an aminoglycoside antibiotic that is mostly used for the pediatric population. While the pediatric population is classified into neonates, infants, children, and adolescents based on developmental or maturational changes, infants are often overlooked in research. Three infant cases receiving gentamicin are presented to illustrate the pharmacokinetics and optimum dosage of gentamicin. Three infant patients received gentamicin (5.6-7.5 mg/kg/day) for urinary tract infections (UTIs) or bacteremia caused by Enterobacter aerogenes. The trough (Cmin) and peak (Cpeak) concentrations of gentamicin were 0.2-1.8 and 8.9 mg/L, respectively. The Cmin of a patient receiving gentamicin at 9.0 mg/kg/day was 3.3 mg/L, and the patient showed a decrease in urinary volume. The other two patients fully recovered from the infection and did not experience any adverse events. Additionally, we reviewed three studies regarding infant patients receiving gentamicin. The studies used gentamicin therapy for Gram-negative pathogen infections and UTIs caused by Escherichia coli and Enterococcus faecalis. The Cmin and Cpeak of patients receiving gentamicin at 2.2-7.5 mg/kg/day were 0.58-2.15 mg/kg and 4.67-8.88 mg/L, respectively. All patients were cured without any adverse events. Gentamicin dosages below 7.5 mg/kg/day may be effective and safe for use in infant patients. However, the optimal dosing regimen of gentamicin in infant patients is controversial, and limited data are available.
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Affiliation(s)
- Hideo Kato
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Mao Hagihara
- Department of Molecular Epidemiology and Biomedical Sciences, Aichi Medical University Hospital, Nagakute 480-1195, Japan
| | - Hiroko Matsuda
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Tsu 514-8507, Japan
- Department of Clinical Pharmaceutics, Division of Clinical Medical Science, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
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Viaggi B, Cangialosi A, Langer M, Olivieri C, Gori A, Corona A, Finazzi S, Di Paolo A. Tissue Penetration of Antimicrobials in Intensive Care Unit Patients: A Systematic Review-Part II. Antibiotics (Basel) 2022; 11:antibiotics11091193. [PMID: 36139972 PMCID: PMC9495066 DOI: 10.3390/antibiotics11091193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022] Open
Abstract
In patients that are admitted to intensive care units (ICUs), the clinical outcome of severe infections depends on several factors, as well as the early administration of chemotherapies and comorbidities. Antimicrobials may be used in off-label regimens to maximize the probability of therapeutic concentrations within infected tissues and to prevent the selection of resistant clones. Interestingly, the literature clearly shows that the rate of tissue penetration is variable among antibacterial drugs, and the correlation between plasma and tissue concentrations may be inconstant. The present review harvests data about tissue penetration of antibacterial drugs in ICU patients, limiting the search to those drugs that mainly act as protein synthesis inhibitors and disrupting DNA structure and function. As expected, fluoroquinolones, macrolides, linezolid, and tigecycline have an excellent diffusion into epithelial lining fluid. That high penetration is fundamental for the therapy of ventilator and healthcare-associated pneumonia. Some drugs also display a high penetration rate within cerebrospinal fluid, while other agents diffuse into the skin and soft tissues. Further studies are needed to improve our knowledge about drug tissue penetration, especially in the presence of factors that may affect drug pharmacokinetics.
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Affiliation(s)
- Bruno Viaggi
- Department of Anesthesiology, Neuro-Intensive Care Unit, Careggi University Hospital, 50139 Florence, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Alice Cangialosi
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Martin Langer
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Carlo Olivieri
- Anesthesia and Intensive Care, Sant’Andrea Hospital, ASL VC, 13100 Vercelli, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020 Ranica, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Correspondence:
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Duong A, Simard C, Williamson D, Marsot A. Model Re-Estimation: An Alternative for Poor Predictive Performance during External Evaluations? Example of Gentamicin in Critically Ill Patients. Pharmaceutics 2022; 14:pharmaceutics14071426. [PMID: 35890322 PMCID: PMC9315759 DOI: 10.3390/pharmaceutics14071426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/03/2022] [Accepted: 07/06/2022] [Indexed: 12/01/2022] Open
Abstract
Background: An external evaluation is crucial before clinical applications; however, only a few gentamicin population pharmacokinetic (PopPK) models for critically ill patients included it in the model development. In this study, we aimed to evaluate gentamicin PopPK models developed for critically ill patients. Methods: The evaluated models were selected following a literature review on aminoglycoside PopPK models for critically ill patients. The data of patients were retrospectively collected from two Quebec hospitals, the external evaluation and model re-estimation were performed with NONMEM® (v7.5) and the population bias and imprecisions were estimated. Dosing regimens were simulated using the best performing model. Results: From the datasets of 39 and 48 patients from the two Quebec hospitals, none of the evaluated models presented acceptable values for bias and imprecision. Following model re-estimations, all models showed an acceptable predictive performance. An a priori dosing nomogram was developed with the best performing re-estimated model and was consistent based on recommended dosing regimens. Conclusion: Due to the poor predictive performance during the external evaluations, the latter must be prioritized during model development. Model re-estimation may be an alternative to developing a new model, especially when most known models display similar covariates.
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Affiliation(s)
- Alexandre Duong
- Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada; (D.W.); (A.M.)
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Correspondence:
| | - Chantale Simard
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Quebec, QC G1V 4G5, Canada;
- Faculté de Pharmacie, Université Laval, Quebec, QC G1V 0A6, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada; (D.W.); (A.M.)
- Hôpital Sacré-Cœur de Montréal, Université de Montréal, Montreal, QC H4J 1C5, Canada
| | - Amélie Marsot
- Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada; (D.W.); (A.M.)
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montreal, QC H3T 1J4, Canada
- Centre de Recherche, CHU Sainte Justine, Montreal, QC H3T 1C5, Canada
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Hodiamont CJ, van den Broek AK, de Vroom SL, Prins JM, Mathôt RAA, van Hest RM. Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review. Clin Pharmacokinet 2022; 61:1075-1094. [PMID: 35754071 PMCID: PMC9349143 DOI: 10.1007/s40262-022-01143-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.
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Affiliation(s)
- Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Suzanne L de Vroom
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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He S, Cheng Z, Xie F. PK/PD guided gentamicin dosing in critically ill patients: a revisit of the Hartford nomogram. Int J Antimicrob Agents 2022; 59:106600. [DOI: 10.1016/j.ijantimicag.2022.106600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/29/2022] [Accepted: 04/28/2022] [Indexed: 11/05/2022]
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He S, Cheng Z, Xie F. Population Pharmacokinetics and Dosing Optimization of Gentamicin in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Drug Des Devel Ther 2022; 16:13-22. [PMID: 35023902 PMCID: PMC8747548 DOI: 10.2147/dddt.s343385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/23/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose Appropriate gentamicin dosing in continuous renal replacement therapy (CRRT) patients remains undefined. This study aimed to develop a population pharmacokinetic (PK) model of gentamicin in CRRT patients and to infer the optimal dosing regimen for gentamicin. Methods Fourteen CRRT patients dosed with gentamicin were included to establish a population PK model to characterize the variabilities and influential covariates of gentamicin. The pharmacokinetic/pharmacodynamic (PK/PD) target attainment and risk of toxicity for different combinations of gentamicin regimens (3–7 mg/kg q24h) and CRRT effluent doses (30–50 mL/h/kg) were evaluated by Monte Carlo simulation. The probability of target attainment (PTA) was determined for the PK/PD indices of the ratio of drug peak concentration/minimum inhibitory concentration (Cmax/MIC > 10) and the ratio of area under the drug concentration–time curve/MIC over 24 h (AUC0-24h/MIC > 100), and the risk of toxicity was estimated by drug trough concentration thresholds (1 and 2 mg/L). Results A one-compartment model adequately described the PK characteristics of gentamicin. Covariates including body weight, age, gender, and CRRT modality did not influence the PK parameters of gentamicin based on our dataset. All studied gentamicin regimens failed to achieve satisfactory PTAs for pathogens with an MIC ≥2 mg/L. A good balance of PK/PD target attainment and risk of toxicity (>2 mg/L) was achieved under 7 mg/kg gentamicin q24h and 40 mL/kg/h CRRT dose for an MIC ≤1 mg/L. CRRT dose intensity had a significant impact on the target attainment of AUC0-24h/MIC >100 and risk of toxicity. Conclusion A combination of 7 mg/kg gentamicin q24h and 40 mL/kg/h CRRT dose might be considered as a starting treatment option for CRRT patients, and drug monitoring is required to manage toxicity.
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Affiliation(s)
- Sha He
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
| | - Zeneng Cheng
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
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Risk Factors Associated with Suboptimal Tobramycin Levels in the Medical Intensive Care Unit. Eur J Drug Metab Pharmacokinet 2022; 47:271-278. [PMID: 35029839 DOI: 10.1007/s13318-021-00749-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Optimal aminoglycoside dosing in critically ill patients represents a challenge for practitioners, especially in the medical intensive care unit (MICU). MICU patients exhibit altered pharmacokinetics due to pathophysiological changes the body undergoes in critical illness, leading to possible treatment failure. The literature surrounding optimal dosing and therapeutic drug monitoring strategies of aminoglycosides in MICU patients is scarce and conflicting. Additionally, only a few studies have investigated risk factors for suboptimal pharmacokinetic target obtainment. Currently, no definitive risk factors have been identified to predict suboptimal aminoglycoside target obtainment in MICU patients. OBJECTIVE The objective of this study was to determine risk factors for suboptimal pharmacokinetic target obtainment in patients receiving tobramycin in the MICU. METHODS This single-center, retrospective cohort study included patients 18-89 years old who received at least one 7 mg/kg tobramycin dose in the MICU from January, 1 2015 to September, 30 2020. Patients also had to have at least two detectable drug levels obtained at least one half-life apart following the first tobramycin dose. The primary outcome was to determine the incidence of optimal pharmacokinetic target obtainment, defined as a tobramycin maximum concentration (Cmax) ≥ 10 mcg/ml, and to identify the risk factors for suboptimal (Cmax < 10 mcg/mL) pharmacokinetic target obtainment, in MICU patients. Secondary outcomes were compared between suboptimal and optimal target obtainment in patients with culture confirmed gram-negative infection susceptible to tobramycin. These secondary outcomes included all-cause in-hospital mortality, ICU length of stay (LOS), hospital LOS, and vasopressor duration in those with shock. RESULTS A total of 230 patients were included in this retrospective study. For the primary outcome, 187 (81.3%) patients achieved optimal target obtainment. Through multivariate logistic regression, female sex and serum albumin < 2.5 g/dL were identified as independent risk factors for suboptimal target obtainment; [OR = 2.14; 95% CI (1.05-4.37), p = 0.037], [OR = 2.50; 95% CI (1.21-5.19), p = 0.014], respectively. Fifty-four (23%) patients had culture-confirmed gram-negative infections susceptible to tobramycin and were included in the subgroup analysis. Of these 54 patients, 11 (20.4%) did not achieve optimal target concentrations. In patients with culture-confirmed gram-negative infection, there was no difference between patients with optimal target obtainment and suboptimal target obtainment in ICU LOS, hospital LOS, all-cause mortality, or vasopressor duration in those with shock. CONCLUSIONS Among patients receiving their first dose of tobramycin in the MICU, 81.3% obtained an optimal serum concentration. Female sex and serum albumin < 2.5 g/dL were identified as risk factors for suboptimal target obtainment; however, further research is warranted to assess the utility of using these two covariates as risk factors for more aggressive dosing in critically ill MICU patients.
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Hodiamont CJ, Juffermans NP, Berends SE, van Vessem DJ, Hakkens N, Mathôt RAA, de Jong MD, van Hest RM. Impact of a vancomycin loading dose on the achievement of target vancomycin exposure in the first 24 h and on the accompanying risk of nephrotoxicity in critically ill patients. J Antimicrob Chemother 2021; 76:2941-2949. [PMID: 34337660 PMCID: PMC8521408 DOI: 10.1093/jac/dkab278] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/09/2021] [Indexed: 12/29/2022] Open
Abstract
Background The advocated pharmacokinetic/pharmacodynamic (PK/PD) target for vancomycin, AUC/MIC ≥ 400 mg·h/L, may not be reached with a conventional fixed starting dose of 1000 mg in critically ill patients, but increasing the dose may cause nephrotoxicity. Objectives To evaluate the effect of a weight-based loading dose of 25 mg/kg vancomycin on PK/PD target attainment in the first 24 h (AUC0–24) in critically ill patients and to evaluate whether this increases the risk of acute kidney injury (AKI). Patients and methods A prospective observational before/after study was performed in ICU patients, comparing the percentage of vancomycin courses with AUC0–24 ≥ 400 mg·h/L and the incidence of AKI, defined as worsening of the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) score. The conventional dose group received 1000 mg of vancomycin as initial dose; the loading dose group received a weight-based loading dose of 25 mg/kg. A population PK model developed using non-linear mixed-effects modelling was used to estimate AUC0–24 in all patients. Results One hundred and four courses from 82 patients were included. With a loading dose, the percentage of courses achieving AUC0–24 ≥ 400 mg·h/L increased significantly from 53.8% to 88.0% (P = 0.0006). The percentage of patients with new-onset AKI was not significantly higher when receiving a 25 mg/kg loading dose (28.6% versus 37.8%; P = 0.48). However, the risk of AKI was significantly higher in patients achieving AUC0–24 > 400 mg·h/L compared with patients achieving AUC < 400 mg·h/L (39.0% versus 14.8%; P = 0.031). Conclusions A weight-based loading dose of 25 mg/kg vancomycin led to significantly more patients achieving AUC0–24 ≥ 400 mg·h/L without increased risk of AKI. However, some harm cannot be ruled out since higher exposure was associated with increased risk of AKI.
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Affiliation(s)
- C J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - N P Juffermans
- Department of Intensive Care, OLVG Hospital, Oosterpark 9, 1091 AC Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - S E Berends
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - D J van Vessem
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - N Hakkens
- Laboratory of Experimental Intensive Care and Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - M D de Jong
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - R M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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De Winter S, van Hest R, Dreesen E, Annaert P, Wauters J, Meersseman W, Van den Eede N, Desmet S, Verelst S, Vanbrabant P, Peetermans W, Spriet I. Quantification and Explanation of the Variability of First-Dose Amikacin Concentrations in Critically Ill Patients Admitted to the Emergency Department: A Population Pharmacokinetic Analysis. Eur J Drug Metab Pharmacokinet 2021; 46:653-663. [PMID: 34297338 DOI: 10.1007/s13318-021-00698-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There may be a difference between the determinants of amikacin exposure in emergency department (ED) versus intensive care (ICU) patients, and the peak amikacin concentration varies widely between patients. Moreover, when the first dose of antimicrobials is administered to septic patients admitted to the ED, fluid resuscitation and vasopressors have just been initiated. Nevertheless, population pharmacokinetic modelling data for amikacin in ED patients are unavailable. OBJECTIVE The aim of this study was to quantify the interindividual variability (IIV) in the pharmacokinetics of amikacin in patients admitted to the ED and to identify the patient characteristics that explain this IIV. METHODS Patients presenting at the ED with severe sepsis or septic shock were randomly assigned to receive amikacin 25 mg/kg or 15 mg/kg intravenously. Blood samples were collected at 1, 6 and 24 h after the onset of the first amikacin infusion. Data were analysed using nonlinear mixed-effects modelling. RESULTS A two-compartment population pharmacokinetic model was developed based on 279 amikacin concentrations from 97 patients. The IIV in clearance (CL) and central distribution volume (V1) were 71% and 26%, respectively. Body mass index (BMI), serum total protein level, serum sodium level, and fluid balance 24 h after amikacin administration explained 30% of the IIV in V1, leaving 18% of the IIV unexplained. BMI and creatinine clearance according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation 24 h after amikacin administration explained 46% of the IIV in CL, and 39% remained unexplained. CONCLUSION The IIV of amikacin pharmacokinetics in ED patients is large. Higher doses may be considered in patients with low serum sodium levels, low total protein levels, or a high fluid balance. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT02365272.
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Affiliation(s)
- Sabrina De Winter
- Department of Pharmacy, Univesity Hospitals Leuven, Leuven, Belgium.
| | - Reinier van Hest
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Erwin Dreesen
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, Drug Delivery and Disposition, KU Leuven, Leuven, Belgium.,BioNotus, Galileilaan 15, 2845, Niel, Belgium
| | - Joost Wauters
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Meersseman
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Nele Van den Eede
- Laboratory of Clinical Bacteriology and Mycology, University Hospitals Leuven, Leuven, Belgium
| | - Stefanie Desmet
- Laboratory of Clinical Bacteriology and Mycology, University Hospitals Leuven, Leuven, Belgium
| | - Sandra Verelst
- Department of Emergency Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Peter Vanbrabant
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Willy Peetermans
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Isabel Spriet
- Department of Pharmacy, Univesity Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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12
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The Synergistic Activity and Optimizing Doses of Tigecycline in Combination with Aminoglycosides against Clinical Carbapenem-Resistant Klebsiella pneumoniae Isolates. Antibiotics (Basel) 2021; 10:antibiotics10060736. [PMID: 34204561 PMCID: PMC8234075 DOI: 10.3390/antibiotics10060736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/05/2021] [Accepted: 06/11/2021] [Indexed: 01/22/2023] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE), especially carbapenem-resistant Klebsiella pneumoniae (CRKP), are among the largest pathogenic threats to humans. The available antibiotic treatment options for combating CRKP are limited. Colistin-resistant Enterobacteriaceae (CoRE) have also been reported worldwide, including in Thailand. Therefore, this study aimed (1) to determine minimum inhibitory concentrations (MICs) and synergistic activities of antibiotics of CRKP, and (2) to determine the probability target of attainment (PTA) and cumulative fraction of response (CFR) using pharmacokinetic/pharmacodynamic (PK/PD) data. Clinical CRKP isolates were obtained from Phramongkutklao Hospital (June to November 2020). Broth microdilution and checkerboard techniques were used to determine the mono- and synergistic activities of antibiotics. Carbapenemase and mcr-1 genes were also identified by polymerase chain reaction (PCR). The optimal antibiotic regimens were evaluated using Monte Carlo simulations. Forty-nine CRKP isolates were collected, 40 of which were CoRKP strains. The MIC50 and MIC90 of tigecycline, amikacin, and gentamicin were 1 and 2 µg/mL, 4 and 16 µg/mL, and 0.25 and 4 µg/mL, respectively. None of any isolates expressed the mcr-1 gene, whereas blaOXA-48 (53.1%) and blaOXA-48 plus blaNDM (42.9%) were detected. Synergistic activity was observed in 8.2% of isolates for tigecycline combined with amikacin or gentamicin. Additive activity was observed in 75.5% of isolates for tigecycline-amikacin and 69.4% for tigecycline-gentamicin, and no antagonism was observed. High-dose antibiotic regimens achieved the PTA target. The general recommended dose of combination regimens began with 200 mg tigecycline and 25 mg/kg amikacin, or 7 mg/kg gentamicin, followed by 100 mg tigecycline every 12 h and 15 mg/kg amikacin or 5 mg/kg gentamicin every 24 h. In conclusion, tigecycline plus aminoglycosides might be a potential regimen against CRKP and CoRKP. The appropriate combination regimen based on MIC-based dose adjustment can improve optimal antibiotic dosing. Further research via clinical studies will be necessary to confirm these results.
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13
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Verrest L, Wasunna M, Kokwaro G, Aman R, Musa AM, Khalil EAG, Mudawi M, Younis BM, Hailu A, Hurissa Z, Hailu W, Tesfaye S, Makonnen E, Mekonnen Y, Huitema ADR, Beijnen JH, Kshirsagar SA, Chakravarty J, Rai M, Sundar S, Alves F, Dorlo TPC. Geographical Variability in Paromomycin Pharmacokinetics Does Not Explain Efficacy Differences between Eastern African and Indian Visceral Leishmaniasis Patients. Clin Pharmacokinet 2021; 60:1463-1473. [PMID: 34105063 PMCID: PMC8585822 DOI: 10.1007/s40262-021-01036-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 11/09/2022]
Abstract
Introduction Intramuscular paromomycin monotherapy to treat visceral leishmaniasis (VL) has been shown to be effective for Indian patients, while a similar regimen resulted in lower efficacy in Eastern Africa, which could be related to differences in paromomycin pharmacokinetics. Methods Pharmacokinetic data were available from two randomized controlled trials in VL patients from Eastern Africa and India. African patients received intramuscular paromomycin monotherapy (20 mg/kg for 21 days) or combination therapy (15 mg/kg for 17 days) with sodium stibogluconate. Indian patients received paromomycin monotherapy (15 mg/kg for 21 days). A population pharmacokinetic model was developed for paromomycin in Eastern African and Indian VL patients. Results Seventy-four African patients (388 observations) and 528 Indian patients (1321 observations) were included in this pharmacokinetic analysis. A one-compartment model with first-order kinetics of absorption and elimination best described paromomycin in plasma. Bioavailability (relative standard error) was 1.17 (5.18%) times higher in Kenyan and Sudanese patients, and 2.46 (24.5%) times higher in Ethiopian patients, compared with Indian patients. Ethiopian patients had an approximately fourfold slower absorption rate constant of 0.446 h–1 (18.2%). Area under the plasma concentration-time curve for 24 h at steady-state (AUCτ,SS) for 15 mg/kg/day (median [interquartile range]) was higher in Kenya and Sudan (172.7 µg·h/mL [145.9–214.3]) and Ethiopia (230.1 µg·h/mL [146.3–591.2]) compared with India (97.26 µg·h/mL [80.83–123.4]). Conclusion The developed model provides detailed insight into the pharmacokinetic differences among Eastern African countries and India, however the resulting differences in paromomycin exposure do not seem to explain the geographical differences in paromomycin efficacy in the treatment of VL patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01036-8.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands.
| | - Monique Wasunna
- Drugs for Neglected Diseases initiative (DNDi) Africa, Nairobi, Kenya
| | - Gilbert Kokwaro
- KEMRI Wellcome Trust Programme, Nairobi, Kenya.,African Centre for Clinical Trials, Nairobi, Kenya
| | - Rashid Aman
- African Centre for Clinical Trials, Nairobi, Kenya
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | - Mahmoud Mudawi
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Northern Border University, Arar, Saudi Arabia
| | - Brima M Younis
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Asrat Hailu
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zewdu Hurissa
- College of Health Sciences, Arsi University, Asella, Ethiopia
| | - Workagegnehu Hailu
- College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Samson Tesfaye
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yalemtsehay Mekonnen
- College of Natural and Computational Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands.,Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Jos H Beijnen
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands
| | - Smita A Kshirsagar
- Department of Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - Jaya Chakravarty
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Madhukar Rai
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Shyam Sundar
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Fabiana Alves
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, PO Box 90440, 1006 BK, Amsterdam, The Netherlands.
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14
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Abstract
BACKGROUND The pharmacokinetic (PK) data of ganciclovir (GCV), a first-line antiviral treatment for cytomegalovirus infections, in critically ill patients are limited. This study aimed at characterizing GCV population PK and interindividual variability (IIV) in intensive care unit (ICU) patients. Secondary objectives were to identify patient characteristics responsible for IIV and simulate GCV exposure for different dosing regimens. METHOD In this retrospective observational study, clinical data and serum GCV levels were collected from ICU patients on intravenous GCV. PK modeling, covariate analyses, and explorative Monte Carlo dosing simulations (MCS) were performed using nonlinear mixed-effects modeling. Bootstrap and visual predictive checks were used to determine model adequacy. RESULTS In total, 128 GCV measurements were obtained from 34 patients. GCV PK conformed to a 1-compartment model with first-order elimination. After multivariate analyses, only the estimated glomerular filtration rate calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula (P < 0.001) was included as a covariate. In the final model, the estimated clearance (CL) and volume of distribution (V1) were 2.3 L/h and 42 L, respectively, for a patient with the median CKD-EPI of the population (65 mL/min per 1.73 m). The association between CKD-EPI and CL decreased the residual variability from 0.56 to 0.43 and V1-IIV from 114% to 80%, whereas CL-IIV changed from 43% to 47%. MCS revealed that a substantial number of patients may not achieve the GCV PK/pharmacodynamic target trough level (>1.5 mg/L) when administering the label-recommended dose reductions for patients with CKD-EPI <50 mL/min. CONCLUSIONS A large IIV was observed in GCV PK among ICU patients. CKD-EPI could partially explain the IIV, although a large part of the variability remains unclear. MCS suggested that recommended dose reductions for CKD-EPI <50 mL/min may lead to subtherapeutic plasma GCV levels in these patients.
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15
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Duong A, Simard C, Wang YL, Williamson D, Marsot A. Aminoglycosides in the Intensive Care Unit: What Is New in Population PK Modeling? Antibiotics (Basel) 2021; 10:antibiotics10050507. [PMID: 33946905 PMCID: PMC8145041 DOI: 10.3390/antibiotics10050507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Although aminoglycosides are often used as treatment for Gram-negative infections, optimal dosing regimens remain unclear, especially in ICU patients. This is due to a large between- and within-subject variability in the aminoglycoside pharmacokinetics in this population. Objective: This review provides comprehensive data on the pharmacokinetics of aminoglycosides in patients hospitalized in the ICU by summarizing all published PopPK models in ICU patients for amikacin, gentamicin, and tobramycin. The objective was to determine the presence of a consensus on the structural model used, significant covariates included, and therapeutic targets considered during dosing regimen simulations. Method: A literature search was conducted in the Medline/PubMed database, using the terms: ‘amikacin’, ‘gentamicin’, ‘tobramycin’, ‘pharmacokinetic(s)’, ‘nonlinear mixed effect’, ‘population’, ‘intensive care’, and ‘critically ill’. Results: Nineteen articles were retained where amikacin, gentamicin, and tobramycin pharmacokinetics were described in six, 11, and five models, respectively. A two-compartment model was used to describe amikacin and tobramycin pharmacokinetics, whereas a one-compartment model majorly described gentamicin pharmacokinetics. The most recurrent significant covariates were renal clearance and bodyweight. Across all aminoglycosides, mean interindividual variability in clearance and volume of distribution were 41.6% and 22.0%, respectively. A common consensus for an optimal dosing regimen for each aminoglycoside was not reached. Conclusions: This review showed models developed for amikacin, from 2015 until now, and for gentamicin and tobramycin from the past decades. Despite the growing challenges of external evaluation, the latter should be more considered during model development. Further research including new covariates, additional simulated dosing regimens, and external validation should be considered to better understand aminoglycoside pharmacokinetics in ICU patients.
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Affiliation(s)
- Alexandre Duong
- Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada; (Y.L.W.); (D.W.); (A.M.)
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada
- Correspondence: ; Tel.: +1-514-343-6111
| | - Chantale Simard
- Faculté de Pharmacie, Université Laval, Québec, QC G1V 0A6, Canada;
- Centre de Recherche, Institut Universitaire de Cardiologie et Pneumologie de Québec, Québec, QC G1V 4G5, Canada
| | - Yi Le Wang
- Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada; (Y.L.W.); (D.W.); (A.M.)
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada; (Y.L.W.); (D.W.); (A.M.)
- Hôpital Sacré-Cœur de Montréal, Montréal, QC H4J 1C5, Canada
| | - Amélie Marsot
- Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada; (Y.L.W.); (D.W.); (A.M.)
- Laboratoire de Suivi Thérapeutique Pharmacologique et Pharmacocinétique, Faculté de Pharmacie, Université de Montréal, Montréal, QC H3T 1J4, Canada
- Centre de Recherche, CHU Sainte Justine, Montréal, QC H3T 1C5, Canada
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16
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Smit C, van Schip AM, van Dongen EPA, Brüggemann RJM, Becker ML, Knibbe CAJ. Dose recommendations for gentamicin in the real-world obese population with varying body weight and renal (dys)function. J Antimicrob Chemother 2020; 75:3286-3292. [PMID: 32785707 PMCID: PMC7566361 DOI: 10.1093/jac/dkaa312] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/15/2020] [Indexed: 01/06/2023] Open
Abstract
Background The impact of weight on pharmacokinetics of gentamicin was recently elucidated for (morbidly) obese individuals with normal renal function. Objectives To characterize the pharmacokinetics of gentamicin in real-world obese patients, ultimately to develop dose recommendations applicable across the entire obese population. Methods In two large Dutch hospitals, all admitted patients with BMI ≥25 kg/m2 with at least one gentamicin administration, at least one gentamicin and at least one creatinine serum concentration measurement were included. Data from one hospital, obtained from electronic health records, combined with prospective data of non-obese and morbidly obese people with normal renal function, served as the training dataset, and data from the second hospital served as the external validation dataset. Results In the training dataset [1187 observations from 542 individuals, total body weight (TBW) 52–221 kg and renal function (CKD-EPI) 5.1–141.7 mL/min/1.73 m2], TBW was identified as a covariate on distribution volume, and de-indexed CKD-EPI and ICU stay on clearance (all P < 0.001). Clearance was 3.53 L/h and decreased by 0.48 L/h with each 10 mL/min reduction in de-indexed CKD-EPI. The results were confirmed in the external validation (321 observations from 208 individuals, TBW 69–180 kg, CKD-EPI 5.3–130.0 mL/min/1.73 m2). Conclusions Based on the study, we propose specific mg/kg dose reductions with decreasing CKD-EPI values for the obese population, and extension of the dosing interval beyond 24 h when CKD-EPI drops below 50 mL/min/1.73 m2. In ICU patients, a 25% dose reduction could be considered. These guidelines can be used to guide safe and effective dosing of gentamicin across the real-world obese population.
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Affiliation(s)
- Cornelis Smit
- Department of Clinical Pharmacy, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands.,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Anne M van Schip
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands.,Department of Hospital Pharmacy, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands.,Faculty of Science and Engineering, Antonius Deusinglaan 1, 9713 AV, University of Groningen, Groningen, The Netherlands
| | - Eric P A van Dongen
- Department of Anesthesiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Roger J M Brüggemann
- Department of Pharmacy, Rdboud Institute for Health Sciences, Radboudumc, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands
| | - Matthijs L Becker
- Pharmacy Foundation of Haarlem Hospitals, Boerhaavelaan 24, 2035 RC Haarlem, The Netherlands.,Department of Hospital Pharmacy, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC Haarlem, The Netherlands
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands.,Department of Systems Biomedicine and Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
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17
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Marsot A, Hraiech S, Cassir N, Daviet F, Parzy G, Blin O, Papazian L, Guilhaumou R. Aminoglycosides in critically ill patients: which dosing regimens for which pathogens? Int J Antimicrob Agents 2020; 56:106124. [PMID: 32739478 DOI: 10.1016/j.ijantimicag.2020.106124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 06/17/2020] [Accepted: 07/23/2020] [Indexed: 12/20/2022]
Abstract
Modifications of antibiotic pharmacokinetic parameters have been reported in critically ill patients, resulting in a risk of treatment failure. We aimed to determine optimised amikacin (AMK), gentamicin (GEN) and tobramycin (TOB) intravenous dosing regimens in this patient population. Patients admitted to the medical ICU and treated with AMK, GEN or TOB were included. Analyses were performed using a parametric population approach. Monte Carlo simulations were performed and the probability of target attainment (PTA) was calculated using Cmax/MIC ≥ 8 and trough concentrations as targets. A total of 117 critically ill hospitalised patients were studied. Median values (interindividual variability, ɷ2) of clearance were 3.51 (0.539), 3.53 (0.297), 2.70 (0.339) and 5.07 (0.339) L/h for AMK, GEN, TOB, and TOB in cystic fibrosis (CF), respectively. Median values (ɷ2) of central volume of distribution were 30.2 (0.215), 20.0 (0.109) and 25.6 (0.177) L for AMK, GEN and TOB, respectively. Simulations showed that doses should be adjusted to actual body weight and creatinine clearance (CLCR) for AMK and GEN, and according to CLCR and presence of CF for TOB. In conclusion, our recommendations for treating Pseudomonas aeruginosa infections in this population include using initial doses of 35 mg/kg for AMK or 10 mg/kg for TOB (CF and non-CF patients). GEN demonstrated the best rates of target attainment against Staphylococcus aureus infections with a dose of 5 mg/kg. As high aminoglycoside doses are required in this population, efficacy and safety targets are conflicting and therapeutic drug monitoring remains an important tool to manage this issue.
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Affiliation(s)
- A Marsot
- Faculté de Pharmacie, Université de Montréal, Montréal, Canada.
| | - S Hraiech
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - N Cassir
- Aix-Marseille Université, IRD, APHM, MEPHI, Marseille, France; IHU Méditerranée Infection, Marseille, France
| | - F Daviet
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - G Parzy
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - O Blin
- IHU Méditerranée Infection, Marseille, France
| | - L Papazian
- Service de Médecine Intensive-Réanimation, APHM, Hôpital Nord, Marseille, France; CEReSS-Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - R Guilhaumou
- Aix-Marseille Univ., APHM, INSERM, CIC CPCET Service de Pharmacologie Clinique et Pharmacovigilance, INS Inst Neurosci Syst, Marseille, France
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18
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Sridharan K, Al Daylami A. Clinical audit of gentamicin use by Bayesian pharmacokinetic approach in critically ill children. J Infect Chemother 2020; 26:540-548. [DOI: 10.1016/j.jiac.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/15/2020] [Accepted: 01/22/2020] [Indexed: 02/09/2023]
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19
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Gatti M. Pharmacokinetic analysis investigating gentamicin dosing in a major burned patient complicated by septic shock. J Chemother 2020; 32:208-212. [DOI: 10.1080/1120009x.2020.1733335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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20
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Considerations for the optimal management of antibiotic therapy in elderly patients. J Glob Antimicrob Resist 2020; 22:325-333. [PMID: 32165285 DOI: 10.1016/j.jgar.2020.02.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 02/14/2020] [Accepted: 02/26/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To maximise efficacy and minimise toxicity, special considerations are required for antibiotic prescription in elderly patients. This review aims to provide practical suggestions for the optimal management of antibiotic therapy in elderly patients. METHODS This was a narrative review. A literature search of published articles in the last 15 years on antibiotics and elderly patients was performed using the Cochrane Library and PubMed electronic databases. The three priority areas were identified: (i) pharmacokinetics/pharmacodynamics (PK/PD) for optimising dosage regimens and route of administration; (ii) antibiotic dosages in some special subpopulations; and (iii) treatment considerations relating to different antibiotic classes and their adverse events. RESULTS Clinicians should understand the altered PK/PD of drugs in this population owing to co-morbid conditions and normal physiological changes associated with ageing. The body of evidence justifies the need for individualised dose selection, especially in patients with impaired renal and liver function. Clinicians should be aware of the major drug-drug interactions commonly observed in the elderly as well as potential side effects. CONCLUSION Antibiotic therapy in the elderly requires a comprehensive approach, including strategies to improve appropriate antibiotic prescribing, limit their use for uncomplicated infections and ensure the attainment of an optimal PK/PD target. To this purpose, further studies involving the elderly are needed to better understand the PK of antibiotics. Moreover, it is necessary to assess the role therapeutic drug monitoring in guiding antibiotic therapy in elderly patients in order to evaluate its impact on clinical outcome.
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21
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Castillo RL, Ibacache M, Cortínez I, Carrasco-Pozo C, Farías JG, Carrasco RA, Vargas-Errázuriz P, Ramos D, Benavente R, Torres DH, Méndez A. Dexmedetomidine Improves Cardiovascular and Ventilatory Outcomes in Critically Ill Patients: Basic and Clinical Approaches. Front Pharmacol 2020; 10:1641. [PMID: 32184718 PMCID: PMC7058802 DOI: 10.3389/fphar.2019.01641] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 12/16/2019] [Indexed: 12/11/2022] Open
Abstract
Dexmedetomidine (DEX) is a highly selective α2-adrenergic agonist with sedative and analgesic properties, with minimal respiratory effects. It is used as a sedative in the intensive care unit and the operating room. The opioid-sparing effect and the absence of respiratory effects make dexmedetomidine an attractive adjuvant drug for anesthesia in obese patients who are at an increased risk for postoperative respiratory complications. The pharmacodynamic effects on the cardiovascular system are known; however the mechanisms that induce cardioprotection are still under study. Regarding the pharmacokinetics properties, this drug is extensively metabolized in the liver by the uridine diphosphate glucuronosyltransferases. It has a relatively high hepatic extraction ratio, and therefore, its metabolism is dependent on liver blood flow. This review shows, from a basic clinical approach, the evidence supporting the use of dexmedetomidine in different settings, from its use in animal models of ischemia-reperfusion, and cardioprotective signaling pathways. In addition, pharmacokinetics and pharmacodynamics studies in obese subjects and the management of patients subjected to mechanical ventilation are described. Moreover, the clinical efficacy of delirium incidence in patients with indication of non-invasive ventilation is shown. Finally, the available evidence from DEX is described by a group of Chilean pharmacologists and clinicians who have worked for more than 10 years on DEX.
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Affiliation(s)
- Rodrigo L Castillo
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Unidad de Paciente Crítico, Hospital del Salvador, Santiago, Chile
| | - Mauricio Ibacache
- Programa de Farmacología y Toxicología & División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ignacio Cortínez
- Programa de Farmacología y Toxicología & División de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Catalina Carrasco-Pozo
- Discovery Biology, Griffith Institute for Drug Discovery, Griffith University, Nathan, QLD, Australia
| | - Jorge G Farías
- Departmento de Ingeniería Química, Facultad de Ingeniería y Ciencias, Universidad de La Frontera, Francisco Salazar, Chile
| | - Rodrigo A Carrasco
- Departamento de Cardiología, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Patricio Vargas-Errázuriz
- Unidad de Paciente Crítico, Hospital del Salvador, Santiago, Chile.,Unidad de Paciente Crítico Adulto, Clínica Universidad de Los Andes, Santiago, Chile.,Unidad de Paciente Crítico, Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Daniel Ramos
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Rafael Benavente
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Daniela Henríquez Torres
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Aníbal Méndez
- Departamento de Medicina Interna Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
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Cano A, Gutiérrez-Gutiérrez B, Machuca I, Gracia-Ahufinger I, Pérez-Nadales E, Causse M, Castón JJ, Guzman-Puche J, Torre-Giménez J, Kindelán L, Martínez-Martinez L, Rodriguez-Baño J, Torre-Cisneros J. Risks of Infection and Mortality Among Patients Colonized With Klebsiella pneumoniae Carbapenemase-Producing K. pneumoniae: Validation of Scores and Proposal for Management. Clin Infect Dis 2019; 66:1204-1210. [PMID: 29126110 DOI: 10.1093/cid/cix991] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background The management and indication of empiric treatment in Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp)-colonized patients should be improved. Methods A prospective cohort of 94 patients colonized by KPC-Kp was followed for 90 days to validate (i) the Giannella risk score (GRS) to predict the development of any type of KPC-Kp infection and (ii) the INCREMENT-CPE score (ICS) to predict 30-day mortality in patients with infection. Both scores were combined to recommend appropriate empiric treatment. The predictive ability of the scores was measured by calculating the area under the receiver operating characteristic (AUROC) curve. Results The GRS showed an AUROC curve for infection due to KPC-Kp of 0.92 (95% confidence interval [CI], .87-.98). The optimal cutoff point was fixed at <7 and ≥7 (92.9% sensitivity, 84.8% specificity); infection developed in 6.3% patients in the 0-6 GRS group and in 84.8% patient in the ≥7 GRS group. According to the ICS, the severity of the infection was also significantly higher in the ≥7 GRS group. The ICS showed an AUROC of 0.78 (95% CI, .65-.91) for 30-day all-cause mortality among patients with infection. A classification and regression tree analysis confirmed the GRS cutoff point at 7, and selected ≥12 points to predict a KPC-Kp infection with a high ICS. Conclusions Our results validate the GRS and ICS for indicating empiric therapy in KPC-Kp-colonized patients.
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Affiliation(s)
- Angela Cano
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Belén Gutiérrez-Gutiérrez
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBiS), Spain.,Department of Medicine, Universidad de Sevilla, Spain
| | - Isabel Machuca
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Irene Gracia-Ahufinger
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Elena Pérez-Nadales
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC)-Reina Sofia University Hospital, University of Córdoba, Spain
| | - Manuel Causse
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Juan José Castón
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Julia Guzman-Puche
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Julian Torre-Giménez
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Lara Kindelán
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
| | - Luis Martínez-Martinez
- Microbiology Unit, Hospital Universitario Reina Sofía-IMIBIC, Universidad de Cordoba, Spain
| | - Jesús Rodriguez-Baño
- Infectious Diseases Unit, Hospital Universitario Virgen Macarena-Instituto de Biomedicina de Sevilla (IBiS), Spain.,Department of Medicine, Universidad de Sevilla, Spain
| | - Julian Torre-Cisneros
- Infectious Diseases Unit, Hospital Universitario Reina Sofía-Instituto Maimónides de Investigación Biomédica de Cordoba (IMIBIC)-Universidad de Cordoba, Spain
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23
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Population Pharmacokinetics with Monte Carlo Simulations of Gentamicin in a Population of Severely Ill Adult Patients from Sub-Saharan Africa. Antimicrob Agents Chemother 2019; 63:AAC.02328-18. [PMID: 30917981 DOI: 10.1128/aac.02328-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/19/2019] [Indexed: 01/13/2023] Open
Abstract
In sub-Saharan Africa (SSA), gentamicin is commonly used for severe infections in non-intensive-care-unit (ICU) settings, but pharmacokinetic and pharmacodynamic data for this specific population are lacking. We performed a population pharmacokinetic study in an adult Mozambican non-ICU hospital population treated with gentamicin (n = 48) and developed a pharmacokinetic model using nonlinear mixed-effects modeling. Simulations showed that non-ICU patient populations in SSA may be at substantial risk for underexposure to gentamicin during routine once-daily dosing.
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24
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Ben Romdhane H, Ben Fredj N, Chaabane A, Ben Aicha S, Chadly Z, Ben Fadhel N, Boughattas N, Aouam K. Interest of therapeutic drug monitoring of aminoglycosides administered by a monodose regimen. Nephrol Ther 2019; 15:110-114. [PMID: 30660586 DOI: 10.1016/j.nephro.2018.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/24/2018] [Accepted: 08/28/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although the once-daily regimen of aminoglycosides (AG) is considered as predominantly used by many centers, the level of evidence of Therapeutic Drug Monitoring (TDM) of AG in cases of once-daily has not been clearly defined. The objective of this study is to evaluate the impact of TDM in achievement or maintaining target serum concentrations in patients receiving once-daily administration of AG. METHODS We performed a retrospective analysis of data from patients having received a once daily amikacin or gentamicin and underwent routine TDM. A longitudinal follow up was performed. Data were analyzed according to the adhesion or not to recommendations. A logistic regression was performed in order to evaluate the effect of covariates (age, gender, weight, creatinine clearance [CLcr], TDM-based dose adjustment, weighted dose of AG) on the achievement of non-toxic Cmin. RESULTS A total 437 blood samples issued from 324 patients were analyzed. The cut-off value of Clcr associated with a risk of toxic Cmin was≤41.66mL/min (OR: 11.29; 95%CI: 7.21-17.61; P<0.0001). Eighty-eight patients (27.1%) have at least two sampling points. The univariate analysis showed that the age, weight, CLcr and TDM-based dose adjustment were found to be significant factors in the achievement of non-toxic Cmin. In multivariate analysis, only TDM-based dose adjustment remains a significant factor in the achievement of non-toxic Cmin (OR: 6.66; 95%CI: 2.26-19.63; P=0.0006). CONCLUSION Our study demonstrates the usefulness of TDM-based dosing adjustment of AG antibiotics in achieving nontoxic trough concentrations, particularly in critically ill patients, as they are prone to a renal impairment.
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Affiliation(s)
- Haifa Ben Romdhane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Nadia Ben Fredj
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia.
| | - Amel Chaabane
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Sana Ben Aicha
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Zohra Chadly
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Najeh Ben Fadhel
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Naceur Boughattas
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
| | - Karim Aouam
- EPS Monastir, service de pharmacologie clinique, laboratoire de pharmacologie, faculté de médecine de Monastir, rue Avicenne, 5019 Monastir, Tunisia
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25
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Boisson M, Mimoz O, Hadzic M, Marchand S, Adier C, Couet W, Grégoire N. Pharmacokinetics of intravenous and nebulized gentamicin in critically ill patients. J Antimicrob Chemother 2018; 73:2830-2837. [DOI: 10.1093/jac/dky239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/23/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Matthieu Boisson
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- CHU de Poitiers, Département d’Anesthésie-Réanimation, 2 rue de la milétrie, Poitiers, France
| | - Olivier Mimoz
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- CHU de Poitiers, Service des Urgences – SAMU 86 – SMUR, 2 rue de la milétrie, Poitiers, France
| | - Mirza Hadzic
- CHU de Poitiers, Département d’Anesthésie-Réanimation, 2 rue de la milétrie, Poitiers, France
| | - Sandrine Marchand
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- CHU de Poitiers, Service de Toxicologie-Pharmacocinétique, 2 rue de la milétrie, Poitiers, France
| | - Christophe Adier
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- CHU de Poitiers, Service de Toxicologie-Pharmacocinétique, 2 rue de la milétrie, Poitiers, France
| | - William Couet
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
- CHU de Poitiers, Service de Toxicologie-Pharmacocinétique, 2 rue de la milétrie, Poitiers, France
| | - Nicolas Grégoire
- Inserm U1070, Pôle Biologie Santé, 1 rue Georges Bonnet, Poitiers, France
- Université de Poitiers, UFR Médecine-Pharmacie, 6 rue de la milétrie, Poitiers, France
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Singu BS, Mubita M, Thikukutu MM, Mufenda JK, McKenzie SB, Verbeeck RK. Monitoring of gentamicin serum concentrations in obstetrics and gynaecology patients in Namibia. Int J Clin Pharm 2018; 40:520-525. [DOI: 10.1007/s11096-018-0626-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/19/2018] [Indexed: 11/28/2022]
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27
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Boidin C, Jenck S, Bourguignon L, Torkmani S, Roussey-Jean A, Ledochowski S, Marry L, Ammenouche N, Dupont H, Marçon F, Allaouchiche B, Bohé J, Lepape A, Goutelle S, Friggeri A. Determinants of amikacin first peak concentration in critically ill patients. Fundam Clin Pharmacol 2018; 32:669-677. [PMID: 29660162 DOI: 10.1111/fcp.12374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/26/2018] [Accepted: 04/09/2018] [Indexed: 11/29/2022]
Abstract
Amikacin antimicrobial effect has been correlated with the ratio of the peak concentration (Cmax ) to the minimum inhibitory concentration. A target Cmax ≥ 60-80 mg/L has been suggested. It has been shown that such target is not achieved in a large proportion of critically ill patients in intensive care units. A retrospective analysis was performed to examine the determinants of Cmax ≥ 80 mg/L on the first peak in 339 critically ill patients treated by amikacin. The influence of available variables on Cmax target attainment was analyzed using a classification and regression tree (CART) and logistic regression. Mean Cmax in the 339 patients was 73.0 ± 23.9 mg/L, with a target attainment rate (TAR, Cmax ≥ 80 mg/L) of 37.5%. In CART analysis, the strongest predictor of amikacin target peak attainment was dose per kilogram of lean body weight (dose/LBW). TAR was 60.1% in patients with dose/LBW ≥ 37.8 vs. 19.9% in patients with lower dose/LBW (OR = 6.0 (95% CI: 3.6-10.2)). Renal function was a secondary predictor of Cmax . Logistic regression analysis identified dose per kilogram of ideal body weight (OR = 1.13 (95% CI: 1.09-1.17)) and creatinine clearance (OR = 0.993 (95% CI: 0.988-0.998)) as predictors of target peak achievement. Based on our results, an amikacin dose ≥ 37.8 mg/kg of LBW should be used to optimize the attainment of Cmax ≥ 80 mg/L after the first dose in critically ill patients. An even higher dose may be necessary in patients with normal renal function.
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Affiliation(s)
- Clément Boidin
- Groupement Hospitalier Nord, Service de Pharmacie, Hôpital Pierre Garraud, Hospices Civils de Lyon, 136 rue du Commandant Charcot, 69322, LyonCedex 5, France.,Laboratoire de Biométrie et Biologie Évolutive, Université Claude Bernard Lyon 1, UMR CNRS 5558, University of Lyon, Bât. Grégor Mendel, 43 bd du 11 novembre 1918, 69622, Villeurbanne Cedex, France
| | - Sophie Jenck
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France
| | - Laurent Bourguignon
- Groupement Hospitalier Nord, Service de Pharmacie, Hôpital Pierre Garraud, Hospices Civils de Lyon, 136 rue du Commandant Charcot, 69322, LyonCedex 5, France.,Laboratoire de Biométrie et Biologie Évolutive, Université Claude Bernard Lyon 1, UMR CNRS 5558, University of Lyon, Bât. Grégor Mendel, 43 bd du 11 novembre 1918, 69622, Villeurbanne Cedex, France.,ISPB - Faculté de Pharmacie de Lyon, Université Claude Bernard Lyon 1, University of Lyon, 8 Avenue Rockefeller, 69003, Lyon, France
| | - Sejad Torkmani
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France
| | - Aurore Roussey-Jean
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France
| | - Stanislas Ledochowski
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France
| | - Lucie Marry
- Service d'Anesthésie et de Réanimation, Centre Hospitalier Universitaire Amiens-Picardie, Site Sud, 80054, Amiens Cedex 1, France
| | - Nacim Ammenouche
- Service d'Anesthésie et de Réanimation, Centre Hospitalier Universitaire Amiens-Picardie, Site Sud, 80054, Amiens Cedex 1, France
| | - Hervé Dupont
- Service d'Anesthésie et de Réanimation, Centre Hospitalier Universitaire Amiens-Picardie, Site Sud, 80054, Amiens Cedex 1, France
| | - Frédéric Marçon
- Service de Pharmacie, Centre Hospitalier Universitaire Amiens-Picardie, Site Sud, 80054, Amiens Cedex 1, France
| | - Bernard Allaouchiche
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.,Faculté de Médecine Lyon Sud-Charles Mérieux, Université Claude Bernard Lyon 1, University of Lyon, 165 Rue du Petit Revoyet, 69600, Oullins, France
| | - Julien Bohé
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.,Faculté de Médecine Lyon Sud-Charles Mérieux, Université Claude Bernard Lyon 1, University of Lyon, 165 Rue du Petit Revoyet, 69600, Oullins, France
| | - Alain Lepape
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.,Laboratoire des Pathogènes Émergents, Université Claude Bernard Lyon 1, UMR CNRS 5308, Inserm U1111, Centre International de Recherche en Infectiologie, University of Lyon, 21 avenue Tony Garnier, 69365, Lyon cedex 07, France
| | - Sylvain Goutelle
- Groupement Hospitalier Nord, Service de Pharmacie, Hôpital Pierre Garraud, Hospices Civils de Lyon, 136 rue du Commandant Charcot, 69322, LyonCedex 5, France.,Laboratoire de Biométrie et Biologie Évolutive, Université Claude Bernard Lyon 1, UMR CNRS 5558, University of Lyon, Bât. Grégor Mendel, 43 bd du 11 novembre 1918, 69622, Villeurbanne Cedex, France.,ISPB - Faculté de Pharmacie de Lyon, Université Claude Bernard Lyon 1, University of Lyon, 8 Avenue Rockefeller, 69003, Lyon, France
| | - Arnaud Friggeri
- Groupement Hospitalier Sud, Service d'Anesthésie et de Réanimation, Hospices Civils de Lyon, 165 Chemin du Grand Revoyet, 69495, Pierre-Bénite, France.,Faculté de Médecine Lyon Sud-Charles Mérieux, Université Claude Bernard Lyon 1, University of Lyon, 165 Rue du Petit Revoyet, 69600, Oullins, France.,Laboratoire des Pathogènes Émergents, Université Claude Bernard Lyon 1, UMR CNRS 5308, Inserm U1111, Centre International de Recherche en Infectiologie, University of Lyon, 21 avenue Tony Garnier, 69365, Lyon cedex 07, France
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Therapeutic Drug Monitoring of Gentamicin Peak Concentrations in Critically Ill Patients. Ther Drug Monit 2018; 39:522-530. [PMID: 28682925 DOI: 10.1097/ftd.0000000000000432] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Adequate gentamicin peak concentrations (Cmax) are important for optimal clinical efficacy. Within a critically ill patient, substantial variability in Cmax can occur over time, hampering the usefulness of therapeutic drug monitoring (TDM). The aim of this study was to evaluate the effect of gentamicin dosing based on Cmax after the first dose on gentamicin target attainment in critically ill patients. METHODS From gentamicin-treated critically ill patients, dosing information, clinical parameters, and serum concentrations were collected prospectively. A population pharmacokinetic model was developed using nonlinear mixed-effects modeling to estimate Cmax after each dose. To evaluate the usefulness of routine TDM, percentages of Cmax within (%Cther, 15-20 mg/L), above (>20 mg/L), and below (%Csubther, <15 mg/L) the therapeutic range after the first and second doses were compared. In addition, simulations were performed to evaluate the impact of TDM. RESULTS Four hundred sixteen measurements from 59 patients receiving 130 gentamicin doses were included. In the 30 patients who received >1 dose, TDM increased %Cther from 40% after a first median dose of 5.0 mg/kg to 50% after the second dose, and decreased %Csubther from 47% to 30%. Simulations using a 5 mg/kg starting dose revealed %Cther after the second dose of 28.4% without and 36.8% with TDM and %Csubther of 56.9% and 29.3%, respectively. Increasing the simulated starting dose to 6 mg/kg increased %Cther after the first dose from 27.7% to 33.5% and decreased %Csubther from 58.6% to 35.6%. TDM after a first dose of 6 mg/kg had no substantial effect on %Cther or %Csubther after the second dose. CONCLUSIONS Gentamicin dosing based on Cmax after the first dose increased %Cther and decreased %Csubther, but did not result in therapeutic Cmax in half of the patients. When simulating a higher starting dose, %Csubther after the first dose decreased, and TDM showed no additional influence. These data suggest that a starting dose of 6 mg/kg should be considered and that repeated Cmax measurements are not of added value.
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29
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Bukkems LH, Roger C, Hodiamont CJ, Lefrant JY, Juffermans NP, Roberts JA, van Hest RM. Predictive performance of a gentamicin population pharmacokinetic model in two western populations of critically ill patients. Int J Antimicrob Agents 2018; 52:218-225. [PMID: 29704547 DOI: 10.1016/j.ijantimicag.2018.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/20/2018] [Accepted: 04/19/2018] [Indexed: 12/12/2022]
Abstract
External validation of population pharmacokinetic (PK) models is warranted before they can be clinically applied to aid in antibiotic dose selection. The primary objective of this study was to assess the predictive performance of a gentamicin population PK model in intensive care unit (ICU) patients in two independent western populations of critically ill patients. METHODS Data were collected from the ICU where the model was developed (Academic Medical Centre, Amsterdam [AMC]) and from the Centre Hospitalier Universitaire de Nîmes (CHU Nîmes). Primary endpoints were bias and accuracy. The model was regarded as valid if bias was not significantly different from 0 and accuracy was equal to or less than 2.5 mg/L. Non-linear mixed-effects modelling (NONMEM) was used for data analysis. RESULTS The AMC validation dataset consisted of 192 samples from 66 ICU patients and the CHU Nîmes dataset of 230 gentamicin samples from 50 ICU patients. The structural model predicted the gentamicin plasma concentrations in the AMC population with a non-significant bias (0.35, 95%CI: -0.11-0.81) and a sufficient accuracy of 2.5 mg/L (95%CI: 2.3-2.8). The gentamicin plasma concentrations were overpredicted in the CHU Nîmes population with a significant bias of 4.8 mg/L (95%CI: 4.00-5.62) and an accuracy of 5.5 mg/L (95%CI: 4.7-6.2). CONCLUSION The model is valid for use in the AMC ICU population but not in the CHU Nîmes ICU population. This illustrates that caution is needed when using a population PK model in an external population.
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Affiliation(s)
- Laura H Bukkems
- Department of Hospital Pharmacy & Clinical Pharmacology, Academic Medical Center, Amsterdam, The Netherlands
| | - Claire Roger
- Service des reanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, Place du Professeur Robert Debré, 3029 Nîmes Cedex 9, France; EA 2992, Faculté de Médicine Montpellier Nîmes, Avenue JF Kennedy, 30 000 Nîmes, France
| | - Caspar J Hodiamont
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jean-Yves Lefrant
- Service des reanimations, Pôle Anesthésie Réanimation Douleur Urgence, CHU Nîmes, Place du Professeur Robert Debré, 3029 Nîmes Cedex 9, France; EA 2992, Faculté de Médicine Montpellier Nîmes, Avenue JF Kennedy, 30 000 Nîmes, France
| | - Nicole P Juffermans
- Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
| | - Jason A Roberts
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Herston, Australia; Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Herston, Australia; Departments for Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Reinier M van Hest
- Department of Hospital Pharmacy & Clinical Pharmacology, Academic Medical Center, Amsterdam, The Netherlands.
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