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Briand A, Bernier L, Pincivy A, Roumeliotis N, Autmizguine J, Marsot A, Métras MÉ, Thibault C. Prolonged Beta-lactam Infusions in Children: A Systematic Review and Meta-analysis. J Pediatr 2024:114220. [PMID: 39097265 DOI: 10.1016/j.jpeds.2024.114220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 07/02/2024] [Accepted: 07/29/2024] [Indexed: 08/05/2024]
Abstract
OBJECTIVE To assess whether beta-lactam extended or continuous beta-lactam infusions (EI/CI) improve clinical outcomes in children with proven or suspected bacterial infections. STUDY DESIGN We included observational and interventional studies that compared beta-lactam EI or CI with standard infusions in children less than 18 years old, and reported on mortality, hospital or intensive care unit LOS, microbiological cure and/or clinical cure. Data sources included PubMed, Medline, EBM Reviews, EMBASE, and CINAHL and were searched from January 1, 1980, to November 3, 2023. Thirteen studies (2,945 patients) were included: 5 randomized control trials (RCTs), and 8 observational studies. Indications for antimicrobial therapies and clinical severity varied, ranging from cystic fibrosis exacerbation to critically ill children with bacteriemia. RESULTS EI and CI were not associated with a reduction in mortality in RCTs (n = 1,464; RR 0.93, 95% CI 0.71, 1.21), but were in observational studies (n = 833; RR 0.43, 95% CI 0.19, 0.96). We found no difference in hospital length of stay. Results for clinical and microbiological cures were heterogeneous and reported as narrative review. The included studies were highly heterogeneous, limiting the strength of our findings. The lack of shared definitions for clinical and microbiological cure outcomes precluded analysis. CONCLUSIONS EI and CI were not consistently associated with reduced mortality or LOS in children. Results were conflicting regarding clinical and microbiological cures. More well-designed studies targeting high-risk populations are necessary to determine the efficacy of these alternative dosing strategies.
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Affiliation(s)
- Annabelle Briand
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Qc, Canada; Department of Pediatrics, CHU Sainte-Justine, Montreal, Qc, Canada
| | - Laurie Bernier
- Faculty of Pharmacy, Université de Montréal, Montreal, Qc, Canada
| | - Alix Pincivy
- Library Services, CHU Sainte-Justine, Montreal, Qc, Canada
| | - Nadia Roumeliotis
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Qc, Canada; Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Qc, Canada; CHU Sainte Justine Research Center, Montreal, Qc, Canada
| | - Julie Autmizguine
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Qc, Canada; Department of Pharmacology and Physiology, Université de Montréal, CHU Sainte-Justine, Montreal, Qc, Canada; Division of Infectious Diseases, Department of Pediatrics, CHU Sainte-Justine, Montreal, Qc, Canada; CHU Sainte Justine Research Center, Montreal, Qc, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, Montreal, Qc, Canada; CHU Sainte Justine Research Center, Montreal, Qc, Canada
| | - Marie-Élaine Métras
- Faculty of Pharmacy, Université de Montréal, Montreal, Qc, Canada; Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Qc, Canada; CHU Sainte Justine Research Center, Montreal, Qc, Canada
| | - Celine Thibault
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montreal, Qc, Canada; Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Qc, Canada; CHU Sainte Justine Research Center, Montreal, Qc, Canada.
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Alsultan A, Aldawsari MR, Alturaiq NK, Syed SA, Alsubai A, Kurdee Z, Alsubaie S, Alqahtani S, Abouelkheir M. Evaluation of pharmacokinetic pharmacodynamic target attainment of meropenem in pediatric patients. Pediatr Neonatol 2024; 65:386-390. [PMID: 38218717 DOI: 10.1016/j.pedneo.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/27/2023] [Accepted: 09/08/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Meropenem is a widely used carbapenem for treating severe pediatric infections. However, few studies have assessed its pharmacokinetics/pharmacodynamics (PK/PD) in pediatric patients. This study aimed to evaluate the proportion of Saudi pediatric patients achieving the PK/PD target of meropenem. METHODS A prospective observational study was conducted at King Saud University Medical City from July to September 2022. Pediatric patients receiving meropenem for suspected or proven infections were included in the study. The primary outcome was the percentage of patients achieving the recommended PK/PD target for critically ill or non-critically ill pediatric patients. RESULTS The study included 30 patients (nine neonates and 21 older pediatric patients). All neonates were critically ill. Among them, 55 % achieved the PK/PD target of 100 % free time above the MIC. In older ICU pediatric patients, only 11 % attained this target, whereas 58 % of older pediatrics in the general wards achieved the PK/PD target of 50 % free time above the MIC. Augmented renal clearance (ARC) was identified in 57 % of our pediatric patient population, none of whom achieved the recommended PK/PD targets. The median trough concentrations in patients with and without ARC were 0.75 and 1.3 μg/mL, respectively (P < 0.05). CONCLUSIONS The majority of patients in our cohort did not achieve the PK/PD target for meropenem. ARC emerged as a major risk factor for target attainment failure in both critically ill and non-critically ill pediatric patients.
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Affiliation(s)
- Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia.
| | - Maram R Aldawsari
- Department of Pharmacy, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Nujood Khaled Alturaiq
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Ali Syed
- Department of Pharmaceutical, Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alsubai
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Zeyad Kurdee
- Clinical Biochemistry Unit, Department of Pathology, College of Medicine, King Saud University, Saudi Arabia
| | - Sarah Alsubaie
- Pediatric Infectious Disease Unit, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Saeed Alqahtani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia; Clinical Pharmacokinetics and Pharmacodynamics Unit, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Manal Abouelkheir
- Department of Clinical Pharmacy, Faculty of Pharmacy, Misr International University, Cairo, Egypt.
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Butragueño-Laiseca L, Troconiz IF, Grau S, Campillo N, Padilla B, Fernández SN, Slöcker M, Herrera L, Santiago MJ. How to use meropenem in pediatric patients undergoing CKRT? Integrated meropenem pharmacokinetic model for critically ill children. Antimicrob Agents Chemother 2024:e0172923. [PMID: 38656186 DOI: 10.1128/aac.01729-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/27/2024] [Indexed: 04/26/2024] Open
Abstract
Standard dosing could fail to achieve adequate systemic concentrations in ICU children or may lead to toxicity in children with acute kidney injury. The population pharmacokinetic analysis was used to simultaneously analyze all available data (plasma, prefilter, postfilter, effluent, and urine concentrations) and provide the pharmacokinetic characteristics of meropenem. The probability of target fT > MIC attainment, avoiding toxic levels, during the entire dosing interval was estimated by simulation of different intermittent and continuous infusions in the studied population. A total of 16 critically ill children treated with meropenem were included, with 7 of them undergoing continuous kidney replacement therapy (CKRT). Only 33% of children without CKRT achieved 90% of the time when the free drug concentration exceeded the minimum inhibitory concentration (%fT > MIC) for an MIC of 2 mg/L. In dose simulations, only continuous infusions (60-120 mg/kg in a 24-h infusion) reached the objective in patients <30 kg. In patients undergoing CKRT, the currently used schedule (40 mg/kg/12 h from day 2 in a short infusion of 30 min) was clearly insufficient in patients <30 kg. Keeping the dose to 40 mg/kg q8h without applying renal adjustment and extended infusions (40 mg/kg in 3- or 4-h infusion every 12 h) was sufficient to reach 90% fT > MIC (>2 mg/L) in patients >10 kg. In patients <10 kg, only continuous infusions reached the objective. In patients >30 kg, 60 mg/kg in a 24-h infusion is sufficient and avoids toxicity. This population model could help with an individualized dosing approach that needs to be adopted in critically ill pediatric patients. Critically ill patients subjected to or not to CKRT may benefit from the administration of meropenem in an extended or continuous infusion.
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Affiliation(s)
- Laura Butragueño-Laiseca
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Iñaki F Troconiz
- Pharmacometrics and Systems Pharmacology Research Unit, Department of Pharmaceutical Sciences, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain
- IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Nuria Campillo
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Belén Padilla
- Clinical Microbiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Sarah Nicole Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - María Slöcker
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - Laura Herrera
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
| | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain
- Pediatrics Department, Universidad Complutense de Madrid, Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Carlos III Health Institute, Madrid, Spain
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Morales Junior R, Juodinis VD, Telles JP, Romano P, Duarte NJC, De Souza DC, Santos SRCJ. Pharmacokinetics and Therapeutic Target Attainment of Meropenem in Pediatric Post-Liver Transplant Patients: Extended vs Intermittent Infusion. Transplant Proc 2023; 55:2456-2461. [PMID: 37923571 DOI: 10.1016/j.transproceed.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/16/2023] [Accepted: 09/22/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The aim of this study is to characterize the concentration-time profile, pharmacokinetics parameters, and therapeutic target attainment of meropenem in pediatric post-liver transplant patients according to the duration of infusion. METHODS This is a prospective cohort of pediatric transplant recipients with preserved renal function receiving meropenem 40 mg/kg every 8 hours. The patients were stratified into 2 groups based on infusion duration: G1 (15 minutes of intermittent infusion) and G1 (3 hours of extended infusion). Two blood samples per child were collected during the same interval within 48 hours of starting the antimicrobial. Meropenem concentrations were determined by high-performance liquid chromatography with tandem mass spectrometry. Pharmacokinetic parameters were assessed using a noncompartmental analysis. The therapeutic target was defined as 100% of the time above the minimum inhibitory concentration. FINDINGS Fourteen patients with 28 measured meropenem concentrations were included. Lower values of volume of distribution and meropenem clearance compared with other critically ill pediatric populations were found. All patients achieved the therapeutic target against gram-negative pathogens with a minimum inhibitory concentration of ≤8 mg/L. Patients receiving a 15-minute infusion had higher values of peak and trough concentrations, resulting in unnecessary increased total drug exposure when compared to patients receiving a 3-hour infusion (P < .05). CONCLUSIONS Meropenem at 120 mg/kg/d attained the therapeutic target against sensitive microorganisms in pediatric liver transplant recipients. The extended infusion should be preferred for patient safety. Because of the pharmacokinetic changes resulting from liver transplantation, individualized meropenem dosing regimens may be necessary.
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Affiliation(s)
- Ronaldo Morales Junior
- Clinical Pharmacokinetics Center, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil; Pediatric Unit, Hospital Sírio-Libanês, São Paulo, Brazil.
| | | | - João Paulo Telles
- Ac Camargo Cancer Center, Infectious Diseases Department, São Paulo, Brazil
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Budai KA, Tímár ÁE, Obeidat M, Máté V, Nagy R, Harnos A, Kiss-Dala S, Hegyi P, Garami M, Hankó B, Lódi C. Extended infusion of β-lactams significantly reduces mortality and enhances microbiological eradication in paediatric patients: a systematic review and meta-analysis. EClinicalMedicine 2023; 65:102293. [PMID: 38021371 PMCID: PMC10651452 DOI: 10.1016/j.eclinm.2023.102293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Background Paediatric patients are often exposed to subtherapeutic levels or treatment failure of β-lactams, and prolonged infusion may be beneficial. We aimed to investigate the efficacy and safety of extended infusion (EI; defined as ≥3 h) or continuous infusion vs. short, intermittent infusion (SI; defined as ≤60 min) of β-lactams in patients <21 years of age. Methods A systematic review and meta-analysis was conducted to compare EI and continuous infusion with SI of β-lactams in children. A systematic search was performed in MEDLINE (via PubMed), Embase, CENTRAL, and Scopus databases for randomised controlled trials (RCTs) and observational studies published from database inception up to August 22, 2023. Any comparative study concerned with mortality, clinical efficacy, adverse events, or plasma concentrations of β-lactams for any infection was eligible. Case reports, case series, and patients aged >21 years were excluded. Odds ratios (OR) and median differences with 95% confidence intervals (CI) were calculated using a random-effects model. Risk of bias (ROB) was assessed using ROB2 and ROBINS-I tools. The protocol was registered with PROSPERO, CRD42022375397. Findings In total, 19,980 articles were screened, out of which 19 studies (4195 patients) were included in the meta-analysis. EI administration was associated with a significantly lower all-cause mortality in both RCTs and non-RCTs [OR 0.74; CI 0.55-0.99; I2 = 0%; CI 0-58%]. Early microbiological eradication was higher with EI [OR 3.18; CI 2.24-4.51; I2 = 0%; CI 0-90%], but the clinical cure did not differ significantly between the two groups [OR 1.20; CI 0.17-8.71; I2 = 79%; CI 32-93%]. Achieving the optimal plasma level (50-100% fT > MIC) appeared favourable in the EI group compared to the SI. No significant differences were observed in the adverse events. The overall ROB was high because of the small sample sizes and clinically heterogeneous populations. Interpretation Our findings suggest that extended infusion of β-lactams was associated with lower mortality and increased microbiological eradication and was considered safe compared to short-term infusion. Funding None.
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Affiliation(s)
- Kinga Anna Budai
- University Pharmacy, Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Ágnes Eszter Tímár
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Mahmoud Obeidat
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Vanda Máté
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Rita Nagy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Andrea Harnos
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biostatistics at the University of Veterinary Medicine, Budapest, Hungary
| | - Szilvia Kiss-Dala
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Miklós Garami
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
| | - Balázs Hankó
- University Pharmacy, Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Csaba Lódi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, MTA Center of Excellence, Semmelweis University, Budapest, Hungary
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Zyryanov S, Bondareva I, Butranova O, Kazanova A. Population PK/PD modelling of meropenem in preterm newborns based on therapeutic drug monitoring data. Front Pharmacol 2023; 14:1079680. [PMID: 37007022 PMCID: PMC10050386 DOI: 10.3389/fphar.2023.1079680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Preterm neonates rarely participate in clinical trials, this leads to lack of adequate information on pharmacokinetics for most drugs in this population. Meropenem is used in neonates to treat severe infections, and absence of evidence-based rationale for optimal dosing could result in mismanagement.Aim: The objective of the study was to determine the population pharmacokinetic (PK) parameters of meropenem in preterm infants from therapeutic drug monitoring (TDM) data in real clinical settings and to evaluate pharmacodynamics (PD) indices as well as covariates affecting pharmacokinetics.Materials and methods: Demographic, clinical and TDM data of 66 preterm newborns were included in PK/PD analysis. The NPAG program from the Pmetrics was used for modelling based on peak-trough TDM strategy and one-compartment PK model. Totally, 132 samples were assayed by high-performance liquid chromatography. Meropenem empirical dosage regimens (40–120 mg/kg/day) were administered by 1–3-h IV infusion 2–3 times a day. Regression analysis was used to evaluate covariates (gestation age (GA), postnatal age (PNA), postconceptual age (PCA), body weight (BW), creatinine clearance, etc.) influenced on PK parameters.Results: The mean ± SD (median) values for constant rate of elimination (Kel) and volume of distribution (V) of meropenem were estimated as 0.31 ± 0.13 (0.3) 1/h and 1.2 ± 0.4 (1.2) L with interindividual variability (CV) of 42 and 33%, respectively. The median values for total clearance (CL) and elimination half-life (T1/2) were calculated as 0.22 L/h/kg and 2.33 h with CV = 38.0 and 30.9%. Results of the predictive performance demonstrated that the population model by itself gives poor prediction, while the individualized Bayesian posterior models give much improved quality of prediction. The univariate regression analysis revealed that creatinine clearance, BW and PCA influenced significantly T1/2, meropenem V was mostly correlated with BW and PCA. But not all observed PK variability can be explained by these regression models.Conclusion: A model-based approach in conjunction with TDM data could help to personalize meropenem dosage regimen. The estimated population PK model can be used as Bayesian prior information to estimate individual PK parameter values in the preterm newborns and to obtain predictions of desired PK/PD target once the patient’s TDM concentration(s) becomes available.
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Affiliation(s)
- Sergey Zyryanov
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
- State Budgetary Institution of Healthcare of the City of Moscow “City Clinical Hospital No. 24 of the Moscow City Health Department, Moscow, Russia
| | - Irina Bondareva
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
| | - Olga Butranova
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
- *Correspondence: Olga Butranova,
| | - Alexandra Kazanova
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia (RUDN University), Moscow, Russia
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