Determination of vancomycin exposure target and individualised dosing recommendations for neonates: model-informed precision dosing

Model-informed drug development in pediatric, pregnancy and geriatric drug development: States of the art and future

The challenges of drug development in pediatric, pregnant and geriatric populations are a worldwide concern shared by regulatory authorities, pharmaceutical companies, and healthcare professionals. Model-informed drug development (MIDD) can integrate and quantify real-world data of physiology, pharmacology, and disease processes by using modeling and simulation techniques to facilitate decision-making in drug development. In this article, we reviewed current MIDD policy updates, reflected on the integrity of physiological data used for MIDD and the effects of physiological changes on the drug PK, as well as summarized current MIDD strategies and applications, so as to present the state of the art of MIDD in pediatric, pregnant and geriatric populations. Some considerations are put forth for the future improvements of MIDD including refining regulatory considerations, improving the integrity of physiological data, applying the emerging technologies, and exploring the application of MIDD in new therapies like gene therapies for special populations.

Population pharmacokinetic analysis for dose regimen optimization of vancomycin in Southern Chinese children

Changes in physiological factors may result in large pharmacokinetic variability of vancomycin in pediatric patients, thereby leading to either supratherapeutic or subtherapeutic exposure and potentially affecting clinical outcomes. This study set out to characterize the disposition of vancomycin, quantify the exposure target and establish an optimal dosage regimen among the Southern Chinese pediatric population. Routine therapeutic drug monitoring data of 453 patients were available. We performed a retrospective population pharmacokinetic analysis of hospitalized children prescribed intravenous vancomycin using NONMEM® software. A one-compartment PPK model of vancomycin with body weight and renal functions as covariates based on a cutoff of 2 years old children was proposed in this study. Both internal and external validation showing acceptable and robust predictive performance of the model to estimate PK parameters. The value of area under the curve over 24 h to minimum inhibitory concentration ratio (AUC0-24/MIC) ≥ 260 was a significant predictor for therapeutic efficacy. Monte Carlo simulations served as a model-informed precision dosing approach and suggested that different optimal dose regimens in various scenarios should be considered rather than flat dosing. The evaluation of vancomycin exposure-efficacy relationship indicated that lower target level of AUC0-24/MIC may be needed to achieve clinical effectiveness in children, which was used to derive the recommended dosing regimen. Further prospective studies will be needed to corroborate and elucidate these results.

Optimization of Vancomycin Initial Dosing Regimen in Neonates Using an Externally Evaluated Population Pharmacokinetic Model

BACKGROUND

Vancomycin therapeutic monitoring guidelines were revised in March 2020, and a population pharmacokinetics-guided Bayesian approach to estimate the 24-hour area under the concentration-time curve to the minimum inhibitory concentration ratio has since been recommended instead of trough concentrations. To comply with these latest guidelines, we evaluated published population pharmacokinetic models of vancomycin using an external dataset of neonatal patients and selected the most predictive model to develop a new initial dosing regimen.

METHODS

The models were identified from the literature and tested using a retrospective dataset of Canadian neonates. Their predictive performance was assessed using prediction- and simulation-based diagnostics. Monte Carlo simulations were performed to develop the initial dosing regimen with the highest probability of therapeutic target attainment.

RESULTS

A total of 144 vancomycin concentrations were derived from 63 neonates in the external population. Five of the 28 models retained for evaluation were found predictive with a bias of 15% and an imprecision of 30%. Overall, the Grimsley and Thomson model performed best, with a bias of -0.8% and an imprecision of 20.9%; therefore, it was applied in the simulations. A novel initial dosing regimen of 15 mg/kg, followed by 11 mg/kg every 8 hours should favor therapeutic target attainment.

CONCLUSIONS

A predictive population pharmacokinetic model of vancomycin was identified after an external evaluation and used to recommend a novel initial dosing regimen. The implementation of these model-based tools may guide physicians in selecting the most appropriate initial vancomycin dose, leading to improved clinical outcomes.

Subgroup identification-based model selection to improve the predictive performance of individualized dosing

Currently, model-informed precision dosing uses one population pharmacokinetic model that best fits the target population. We aimed to develop a subgroup identification-based model selection approach to improve the predictive performance of individualized dosing, using vancomycin in neonates/infants as a test case. Data from neonates/infants with at least one vancomycin concentration was randomly divided into training and test dataset. Population predictions from published vancomycin population pharmacokinetic models were calculated. The single best-performing model based on various performance metrics, including median absolute percentage error (APE) and percentage of predictions within 20% (P20) or 60% (P60) of measurement, were determined. Clustering based on median APEs or clinical and demographic characteristics and model selection by genetic algorithm was used to group neonates/infants according to their best-performing model. Subsequently, classification trees to predict the best-performing model using clinical and demographic characteristics were developed. A total of 208 vancomycin treatment episodes in training and 88 in test dataset was included. Of 30 identified models from the literature, the single best-performing model for training dataset had P20 26.2-42.6% in test dataset. The best-performing clustering approach based on median APEs or clinical and demographic characteristics and model selection by genetic algorithm had P20 44.1-45.5% in test dataset, whereas P60 was comparable. Our proof-of-concept study shows that the prediction of the best-performing model for each patient according to the proposed model selection approaches has the potential to improve the predictive performance of model-informed precision dosing compared with the single best-performing model approach.

Incidence of Antimicrobial-Associated Acute Kidney Injury in Children: A Structured Review

Acute kidney injury (AKI) is a commonly reported adverse effect of administration of antimicrobials. While AKI can be associated with poorer outcomes, there is little information available to understand rates of AKI in children exposed to various antimicrobials. We performed a structured review using the PubMed and Embase databases. Articles were included if they provided an AKI definition in patients who were < 19 years of age receiving an antimicrobial and reported the frequency of AKI. Author-defined AKI rates were calculated for each study and mean pooled estimates for each antimicrobial were derived from among all study participants. Pooled estimates were also derived for those studies that reported AKI according to pRIFLE (pediatric risk, injury, failure, loss, end stage criteria), AKIN (acute kidney injury network), or KDIGO (kidney disease improving global outcomes) creatinine criteria. A total of 122 studies evaluating 28 antimicrobials met the inclusion criteria. Vancomycin was the most commonly studied drug: 11,514 courses across 44 included studies. Among the 27,285 antimicrobial exposures, the overall AKI rate was 13.2% (range 0-42.1% by drug), but the rate of AKI varied widely across studies (range 0-68.8%). Cidofovir (42.1%) and conventional amphotericin B (37.0%) had the highest pooled rates of author-defined AKI. Eighty-one studies used pRIFLE, AKIN, or KDIGO AKI criteria and the pooled rates of AKI were similar to author-defined AKI rates. In conclusion, antimicrobial-associated AKI is reported to occur frequently in children, but the rates of AKI varies widely across studies and drugs. Most published studies examined hospitalized patients and heterogeneity in study populations and in author definitions of AKI are barriers to a comparison of nephrotoxicity risk among antimicrobials in children.

Association between vancomycin therapeutic drug monitoring and clinical outcomes in treating neonatal sepsis

BACKGROUND

Neonatal sepsis is commonly treated with vancomycin in the neonatal intensive care unit. Therapeutic drug monitoring of vancomycin is routinely used to personalise dosing to optimise effectiveness and avoid toxicity.

OBJECTIVES

This study aimed to define a target range by evaluating associations between vancomycin trough concentrations or area under the concentration time curve over 24 hours (AUC24h) and clinical outcomes in neonates.

METHODS

Neonates, who were admitted to the neonatal intensive care unit and received intravenous vancomycin, were included in this retrospective cohort study. For evaluating effectiveness, patients who received vancomycin for < 5 days were excluded. The AUC24h was estimated based on a study-derived population pharmacokinetic model. Primary outcomes were persistent/recurrent infections and mortality within 30 days. Secondary outcomes, including acute kidney injury (AKI), were also assessed. Logistic regression and classification and regression tree analyses were performed.

RESULTS

A total of 448 patients (123 patients for effectiveness analysis) were included. A vancomycin trough > 10 mg/L was associated with 70% lower odds of persistent/recurrent infections (adjusted OR 0.30, 95% CI 0.09-0.86; P = 0.023). Patients who took more than a day to reach target range had 1.4 times higher odds of persistent/recurrent infections or death (P = 0.04). A vancomycin trough > 15 mg/L was associated with a three times higher risk of AKI (P = 0.003). An AUC24h of 420-650 mg*h/L was also associated with the lowest risk of composite outcomes (adjusted OR 0.29, 95% CI 0.08-0.86; P = 0.025).

CONCLUSION

A vancomycin trough target range of 10-15 mg/L and achievement of this target within a day of treatment initiation were associated with the most optimal clinical outcomes in treating neonatal sepsis.

Vancomycin efficiency and safety of a dosage of 40–60 mg/kg/d and corresponding trough concentrations in children with Gram-positive bacterial sepsis

Background

Optimal vancomycin trough concentrations and dosages remain controversial in sepsis children. We aim to investigate vancomycin treatment outcomes with a dosage of 40-60 mg/kg/d and corresponding trough concentrations in children with Gram-positive bacterial sepsis from a clinical perspective.

Methods

Children diagnosed with Gram-positive bacterial sepsis and received intravenous vancomycin therapy between January 2017 and June 2020 were enrolled retrospectively. Patients were categorized as success and failure groups according to treatment outcomes. Laboratory, microbiological, and clinical data were collected. The risk factors for treatment failure were analyzed by logistic regression.

Results

In total, 186 children were included, of whom 167 (89.8%) were enrolled in the success group and 19 (10.2%) in the failure group. The initial and mean vancomycin daily doses in failure group were significantly higher than those in success group [56.9 (IQR =42.1-60.0) vs. 40.5 (IQR =40.0-57.1), P=0.016; 57.0 (IQR =45.8-60.0) vs. 50.0 (IQR =40.0-57.6) mg/kg/d, P=0.012, respectively] and median vancomycin trough concentrations were similar between two groups [6.9 (4.0-12.1) vs.7.3 (4.5-10.6) mg/L, P=0.568)]. Moreover, there was no significant differences in treatment success rate between vancomycin trough concentrations ≤15 mg/L and &gt;15 mg/L (91.2% vs. 75.0%, P=0.064). No vancomycin-related nephrotoxicity adverse effects occurred among all enrolled patients. Multivariate analysis revealed that a PRISM III score ≥10 (OR =15.011; 95% CI: 3.937-57.230; P&lt;0.001) was the only independent clinical factor associated with increased incidence of treatment failure.

Conclusions

Vancomycin dosages of 40-60 mg/kg/d are effective and have no vancomycin-related nephrotoxicity adverse effects in children with Gram-positive bacterial sepsis. Vancomycin trough concentrations &gt;15 mg/L are not an essential target for these Gram-positive bacterial sepsis patients. PRISM III scores ≥10 may serve as an independent risk factor for vancomycin treatment failure in these patients.

Determination of vancomycin exposure target and individualized dosing recommendations for critically ill patients undergoing continuous renal replacement therapy

STUDY OBJECTIVE

Few studies have been conducted to quantify the exposure target of vancomycin in intensive care unit (ICU) patients undergoing continuous renal replacement therapy (CRRT) and provide optimized dosage regimens. We aimed to determine vancomycin exposure target and dosing recommendations using data from an open database in critically ill patients undergoing CRRT.

DESIGN

A retrospective observational cohort study.

DATA SOURCE

A large public database.

PATIENTS

The adult patients who received intravenous vancomycin and CRRT treatment in the database between 2017 and 2019 were reviewed to determine eligibility. A total of 180 patients with 1186 observations were included in the population pharmacokinetic (PPK) model development. The clinical efficacy of vancomycin was analyzed in 159 eligible patients.

METHODS

A PPK model was developed to estimate individual pharmacokinetic (PK) parameters. The area under the concentration-time curve (AUC) was estimated by a Bayesian approach based on individual vancomycin concentrations. Multivariate logistic regression analyses were performed to identify the factors of clinical outcomes. Threshold of vancomycin exposure in predicting efficacy was identified via receiver operating characteristic (ROC) curve. Dosing recommendations were designed using Monte Carlo Simulations (MCS) based on the optimized exposure target.

MEASUREMENTS AND MAIN RESULTS

On covariate analysis, CRRT intensity significantly affected vancomycin PK. The AUC above 427 mg*h/L was the only significant predictor of clinical efficacy (adjusted odds ratio (aOR): 1.008, 95% confidence interval (CI): 1.004-1.011, p = 0.000). MCS indicated that vancomycin dosage regimens of 5 mg/kg q12h or 7.5 mg/kg q12h were recommended for patients with CRRT intensities of 20-25 mL/kg/h or 25.1-45 mL/kg/h, respectively.

CONCLUSIONS

An AUC threshold of 427 mg*h/L (assuming the minimal inhibitory concentration (MIC) = 1 mg/L) was a recommended efficacy exposure target of vancomycin for critically ill patients undergoing CRRT. Vancomycin 5-7.5 mg/kg q12h is recommended as the initial dosage regimens for ICU patients undergoing CRRT.

Population pharmacokinetics of vancomycin in very low birth weight neonates

Introduction

Vancomycin dosing in very low birth weight (VLBW) neonates is challenging. Compared with the general neonatal population, VLBW neonates are less likely to achieve the vancomycin therapeutic targets. Current dosing recommendations are based on studies of the general neonatal population, as only a very limited number of studies have evaluated vancomycin pharmacokinetics in VLBW neonates. The main aim of this study was to develop a vancomycin population pharmacokinetic model to optimize vancomycin dosing in VLBW neonates.

Methods

This multicenter study was conducted at six major hospitals in Saudi Arabia. The study included VLBW neonates who received vancomycin and had at least one vancomycin serum trough concentration measurement at a steady state. We developed a pharmacokinetic model and performed Monte Carlo simulations to develop an optimized dosing regimen for VLBW infants. We evaluated two different targets: AUC_0-24 of 400-600 or 400-800 µg. h/mL. We also estimated the probability of trough concentrations >15 and 20 µg/mL.

Results

In total, we included 236 neonates, 162 in the training dataset, and 74 in the validation dataset. A one-compartment model was used, and the distribution volume was significantly associated only with weight, whereas clearance was significantly associated with weight, postmenstrual age (PMA), and serum creatinine (Scr).

Discussion

We developed dosing regimens for VLBW neonates, considering the probability of achieving vancomycin therapeutic targets, as well as different toxicity thresholds. The dosing regimens were classified according to PMA and Scr. These dosing regimens can be used to optimize the initial dose of vancomycin in VLBW neonates.

Evaluation of Neonatal and Paediatric Vancomycin Pharmacokinetic Models and the Impact of Maturation and Serum Creatinine Covariates in a Large Multicentre Data Set

BACKGROUND AND OBJECTIVE

Infants and neonates present a clinical challenge for dosing drugs with high interindividual variability due to these patients' rapid growth and the interplay between maturation and organ function. Model-informed precision dosing (MIPD), which can account for interindividual variability via patient characteristics and Bayesian forecasting, promises to improve individualized dosing strategies in this complex population. Here, we assess the predictive performance of published population pharmacokinetic models describing vancomycin in neonates and infants, and analyze the robustness of these models in the face of clinical uncertainty surrounding covariate values.

METHODS

The predictive precision and bias of nine pharmacokinetic models were compared in a large multi-site data set (N = 2061 patients, 5794 drug levels, 28 institutions) of patients aged 0-365 days. The robustness of model predictions to errors in serum creatinine measurements and gestational age was assessed by using recorded values or by replacing covariate values with 0.3, 0.5 or 0.8 mg/dL or with 40 weeks, respectively.

RESULTS

Of the nine models, two models (Dao and Jacqz-Aigrain) resulted in predicted concentrations within 2.5 mg/L or 15% of the measured values for at least 60% of population predictions. Within individual models, predictive performance often 2 differed in neonates (0-4 weeks) versus older infants (15-52 weeks). For preterm neonates, imputing gestational age as 40 weeks reduced the accuracy of model predictions. Measured values of serum creatinine improved model predictions compared to using imputed values even in neonates ≤1 week of age.

CONCLUSIONS

Several available pharmacokinetic models are suitable for MIPD in infants and neonates. Availability and accuracy of model covariates for patients will be important for guiding dose decision-making.

Optimal exposure to docetaxel in adjuvant chemotherapy for early-stage breast cancer

WHAT IS KNOWN AND OBJECTIVE

Drug-induced neutropenia is the main reason for the dose limitation of docetaxel in patients with breast cancer. The area under the drug concentration-time curve (AUC) of docetaxel is associated with neutropenia. However, the optimal exposure to docetaxel for receiving postoperative adjuvant chemotherapy remains unclear. Therefore, we aimed to evaluate the relationship between the docetaxel AUC and neutropenia, identify potential influencing factors, and explore the best monitoring target for docetaxel when treating patients with early-stage breast cancer using a population pharmacokinetic (PopPK) model.

METHODS

Docetaxel plasma concentration, demographics, clinical data, and related laboratory data were collected. PopPK analyses were performed using a nonlinear mixed-effect modelling program. The docetaxel AUC was determined using the maximum a posteriori Bayesian (MAPB) method. The docetaxel exposure-toxicity threshold measured from the AUC for neutropenia was determined using the receiver operating characteristic (ROC) curve. The correlation between docetaxel exposure and neutropenia was analysed using multivariable logistic regression.

RESULTS

Among the 70 participants, 47 (67.1%) developed severe neutropenia. The PopPK analysis showed that the typical drug clearance (CL) rate was 37.4 L/h. Age was a significant covariate of CL rate, and aspartate aminotransferase and albumin levels were covariables of the volume of distribution. The multivariable regression analysis showed that AUC >3.0 mg.h/L (odds ratio [OR], 5.940; 95% confidence interval [CI], 1.693-20.843; P = 0.005), platinum use (OR, 0.156; 95% CI, 0.043-0.562; P = 0.005) and baseline haemoglobin level (OR, 0.938; 95% CI, 0.887-0.993; P = 0.027) were significant factors influencing the occurrence of grade 3/4 neutropenia. The AUC of first cycle may not predict the occurrence rates of grade 3/4 neutropenia in later cycles.

WHAT IS NEW AND CONCLUSION

We developed a docetaxel PopPK model for patients with early-stage breast cancer. Age and AST and ALB levels were significant covariates. AUC estimated using the MAPB method can predict the toxicity of docetaxel in patients with breast cancer. Docetaxel AUC >3.0 mg.h/L, absence of platinum use and low baseline haemoglobin level were risk factors for docetaxel-induced grade 3/4 neutropenia.

STUDY REGISTRATION

Chinese Clinical Trial Center Registry (ChiCTR2200056460).

Reappraisal of therapeutic vancomycin trough concentrations with empirical dosing in neonatal infections

BACKGROUND

Vancomycin is commonly used for neonatal sepsis. However, consensus on an empirical neonatal vancomycin regimen remains uncertain. We aimed to reappraise the therapeutic optimum concerning vancomycin trough concentrations with empirical dosing and to evaluate the relationship between trough concentrations and predicted 24-h area under the curve (AUC₂₄).

METHODS

This was a 3-year retrospective study. Neonates who were admitted to the neonatal intensive care unit with available vancomycin trough concentrations were enrolled. Trough levels were obtained before the fourth dose. Achievement of goal trough after implementing the vancomycin dosing regimen was based on the Practical Neonatology Medical Manual, published by the National Taiwan University College of Medicine.

RESULTS

A total of 46 neonates were included for analysis. Coagulase-negative staphylococci were the most commonly identified pathogens of sepsis. Among these patients, 22 achieved goal trough levels of 10-20 mcg/mL. Trough levels of 5-10 or >20 mcg/mL occurred in 13 and 11 patients, respectively. A moderately positive correlation between trough and predicted AUC₂₄ was found in all patients (Spearman's rho = 0.676, p < 0.001). In patients with body weight 1200-2000 g and postnatal age >7 days, the serum creatinine of those with trough levels >20 mcg/mL was significantly higher than those with goal trough levels (0.61 vs. 0.45 mg/dL, p = 0.01). Among those with trough levels >20 mcg/mL, 5 patients received ibuprofen for patent ductus arteriosus closing prior to vancomycin treatment (45%, 5/11), compared to only 3 patients with trough levels <20 mcg/mL (9%, 3/35) (p = 0.013).

CONCLUSION

Only half of the neonates receiving empirical vancomycin regimen achieved goal trough levels of 10-20 mcg/mL. Higher serum creatinine or ibuprofen treatment may increase the risk of overly high trough levels. The vancomycin regimen needs further validation and modification to provide adequate dosing for optimal use in neonates.

Optimal exposure targets for vancomycin in the treatment of neonatal coagulase-negative Staphylococcus infection: A retrospective study based on electronic medical records

BACKGROUND

The currently advocated ratio of area under the curve (AUC) over 24 h to minimum inhibitory concentration (AUC/MIC) > 400 and AUC < 600 mg h/L as the therapeutic drug monitoring (TDM) target of vancomycin is based on data from multiple observational studies in adult patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. It may not be applicable to newborns with coagulase-negative Staphylococcus (CoNS) infection. We conducted a retrospective study to identify the optimal exposure targets for vancomycin in the treatment of neonatal CoNS infection.

METHODS

Based on the inclusion and exclusion criteria, serum vancomycin concentration, demographics, clinical data, and related laboratory data of newborns who received vancomycin intravenous infusion from June 1, 2016 to February 1, 2021 were collected retrospectively. The AUC was calculated using the maximum a posteriori Bayesian (MAPB) method. The vancomycin exposure threshold of AUC/MIC for efficacy and AUC for toxicity (acute kidney injury, AKI) were determined based on receiver operating characteristic (ROC) curve analysis. The correlation between vancomycin exposure and both clinical effect and nephrotoxicity was analyzed using logistic multivariate regression.

RESULTS

In total, 153 patients and 245 vancomycin concentrations (160 trough and 85 peak concentrations) were included. The ROC curve analysis showed that the exposure thresholds of AUC/MIC for clinical efficacy and AUC for nephrotoxicity were 281 and 602 mg h/L, respectively. The multivariate regression analysis showed that AUC/MIC > 280 was a predictor of efficacy (OR: 13.960, 95% CI: 1.891-103.078, P < 0.05) and AUC > 600 mg h/L was associated with AKI (OR: 9.008, 95% CI: 2.706-29.983, P < 0.05). The vancomycin AUC/MIC threshold for treating neonatal CoNS infection with vancomycin is lower than the currently advocated AUC/MIC >400.

CONCLUSION

The optimal exposure targets for vancomycin in neonatal CoNS infection were AUC/MIC > 280 and AUC < 600 mg h/L.

Identifying a therapeutic target for vancomycin against staphylococci in young infants

OBJECTIVES

To determine the therapeutic target of vancomycin in young infants with staphylococcal infections.

METHODS

Retrospective data were collected for infants aged 0 to 90 days with CoNS or MRSA bacteraemia over a 4 year period at the Royal Children's Hospital Melbourne, Australia. Vancomycin broth microdilution MICs were determined. A published pharmacokinetic model was externally validated using the study dataset and a time-to-event (TTE) pharmacodynamic model developed to link the AUC of vancomycin with the event being the first negative blood culture. Simulations were performed to determine the trough vancomycin concentration that correlates with a 90% PTA of the target AUC24.

RESULTS

Thirty infants, 28 with CoNS and 2 with MRSA bacteraemia, who had 165 vancomycin concentrations determined were included. The vancomycin broth microdilution MIC was determined for 24 CoNS and 1 MRSA isolate, both with a median MIC of 1 mg/L (CoNS range = 0.5-4.0). An AUC0-24 target of ≥300 mg/L·h or AUC24-48 of ≥424 mg/L·h. increased the chance of bacteriological cure by 7.8- and 7.3-fold, respectively. However, AUC0-24 performed best in the pharmacokinetic-pharmacodynamic model. This correlates with 24 to 48 h trough concentrations of >15-18 mg/L and >10-15 mg/L for 6- and 12-hourly dosing, respectively, and can be used to guide vancomycin therapy in this population.

CONCLUSIONS

An AUC0-24 ≥300 mg/L·h or AUC24-48 ≥424 mg/L·h was associated with an increase in bacteriological cure in young infants with staphylococcal bloodstream infections.

Therapeutic drug monitoring of antimicrobial drugs in neonates. An opinion paper

PURPOSE

Neonatal infections are associated with high morbidity and mortality rates. Optimal treatment of these infections requires knowledge of neonatal pharmacology and integration of neonatal developmental pharmacokinetics of antimicrobial drugs in the design of dosing regimens for use with different gestational and postnatal ages. Population pharmacokinetic (PK) and pharmacodynamic (PD) models are used to personalize the use of these drugs in these fragile patients. The final step to further minimize variability in an individual patient is therapeutic drug monitoring (TDM), where the same population PK/PD models are used in concert with optimally drawn blood samples to further fine-tune therapy. The purpose of this manuscript is to describe the present status and future role of model-based precision dosing and TDM of antimicrobial drugs in neonates.

METHODS

PubMed was searched for clinical trials or clinical studies of TDM in neonates.

RESULTS

A total of 447 papers were retrieved, of which 19 were concerned with antimicrobial drugs. Two papers (one aminoglycoside and one vancomycin) addressed the effects of TDM in neonates. We found that, in addition to aminoglycosides and vancomycin, TDM also plays a role in beta-lactam antibiotics and antifungal drugs.

CONCLUSION

There is a growing awareness that, in addition to aminoglycosides and vancomycin, the use of beta-lactam antibiotics, such as amoxicillin and meropenem, and other classes of antimicrobial drugs, such as antifungal drugs, may benefit from TDM. However, the added value must be shown. New analytical techniques and software development may greatly support these novel developments.