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Liu Q, Huang H, Xu B, Li D, Liu M, Shaik IH, Wu X. Two Innovative Approaches to Optimize Vancomycin Dosing Using Estimated AUC after First Dose: Validation Using Data Generated from Population PK Model Coupled with Monte-Carlo Simulation and Comparison with the First-Order PK Equation Approach. Pharmaceutics 2022; 14:pharmaceutics14051004. [PMID: 35631590 PMCID: PMC9147553 DOI: 10.3390/pharmaceutics14051004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/08/2022] [Accepted: 04/14/2022] [Indexed: 02/04/2023] Open
Abstract
The revised consensus guidelines for optimizing vancomycin doses suggest that maintaining the area under the concentration-time curve to minimal inhibitory concentration ratio (AUC/MIC) of 400–600 mg·h/L is the target pharmacokinetic/pharmacodynamic (PK/PD) index for efficacy. AUC-guided dosing approach uses a first-order pharmacokinetics (PK) equation to estimate AUC using two samples obtained at steady state and one-compartment model, which can cause inaccurate AUC estimation and fail to achieve the effective PK/PD target early in therapy (days 1 and 2). To achieve an efficacy target from the third or fourth dose, two innovative approaches (Method 1 and Method 2) to estimate vancomycin AUC at steady state (AUCSS) using two-compartment model and three or four levels after the first dose are proposed. The feasibility of the proposed methods was evaluated and compared with another published dosing algorithm (Method 3), which uses two samples and a one-compartment approach. Monte Carlo simulation was performed using a well-established population PK model, and concentration-time profiles for virtual patients with various degrees of renal function were generated, with 1000 subjects per group. AUC extrapolated to infinity (AUC0–∞) after the first dose was estimated using the three methods, whereas reference AUC (AUCref) was calculated using the linear-trapezoidal method at steady state after repeated doses. The ratio of AUC0–∞: AUCref and % bias were selected as the indicators to evaluate the accuracy of three methods. Sensitivity analysis was performed to examine the influence of change in each sampling time on the estimated AUC0–∞ using the two proposed approaches. For simulated patients with various creatinine clearance, the mean of AUC0–∞: AUCref obtained from Method 1, Method 2 and Method 3 ranged between 0.98 to 1, 0.96 to 0.99, and 0.44 to 0.69, respectively. The mean bias observed with the three methods was −0.10% to −2.09%, −1.30% to −3.59% and −30.75% to −55.53%, respectively. The largest mean bias observed by changing sampling time while using Method 1 and Method 2 were −4.30% and −10.50%, respectively. Three user-friendly and easy-to-use excel calculators were built based on the two proposed methods. The results showed that our approaches ensured sufficient accuracy and achieved target PK/PD index early and were superior to the published methodologies. Our methodology has the potential to be used for vancomycin dose optimization and can be easily implemented in clinical practice.
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Affiliation(s)
- Qingxia Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, China; (Q.L.); (H.H.); (B.X.); (D.L.); (M.L.)
- School of Pharmacy, Fujian Medical University, Fuzhou 350001, China
| | - Huiping Huang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, China; (Q.L.); (H.H.); (B.X.); (D.L.); (M.L.)
- School of Pharmacy, Fujian Medical University, Fuzhou 350001, China
| | - Baohua Xu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, China; (Q.L.); (H.H.); (B.X.); (D.L.); (M.L.)
- School of Pharmacy, Fujian Medical University, Fuzhou 350001, China
| | - Dandan Li
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, China; (Q.L.); (H.H.); (B.X.); (D.L.); (M.L.)
- School of Pharmacy, Fujian Medical University, Fuzhou 350001, China
| | - Maobai Liu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, China; (Q.L.); (H.H.); (B.X.); (D.L.); (M.L.)
- School of Pharmacy, Fujian Medical University, Fuzhou 350001, China
| | - Imam H. Shaik
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Xuemei Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou 350001, China; (Q.L.); (H.H.); (B.X.); (D.L.); (M.L.)
- School of Pharmacy, Fujian Medical University, Fuzhou 350001, China
- Correspondence: ; Tel.: +86-13365918120
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Kerr RV, Fairbairn JA, Merritt AT, Bugg TDH. Peptidomimetic analogues of an Arg-Trp-x-x-Trp motif responsible for interaction of translocase MraY with bacteriophage ϕX174 lysis protein E. Bioorg Med Chem 2021; 52:116502. [PMID: 34808406 DOI: 10.1016/j.bmc.2021.116502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022]
Abstract
Translocase MraY is the target for bacteriophage ϕX174 lysis protein E, which interacts via a protein-protein interaction mediated by Phe-288 and Glu-287 of E. coli MraY, and an Arg-Trp-x-x-Trp motif on protein E, also found in several cationic antimicrobial peptides. Analogues of Arg-Trp-octyl ester, found previously to show antimicrobial activity, were tested for antimicrobial activity, with Lys-Trp-oct (MIC50P. fluorescens 5 µg/mL) and Arg-Trp-decyl ester (MIC50P. fluorescens 3 µg/mL) showing enhanced antimicrobial activity. Synthesis and testing of α-helix peptidomimetic analogues for this motif revealed improved antibacterial activity (MIC50E. coli 4-7 µg/mL) for analogues containing two aromatic substituents, mimicking the Arg-Trp-x-x-Trp motif, and MraY inhibition (IC50 140 µM) by one such peptidomimetic. Investigation of mechanism of action using the Alamar Blue membrane permeabilisation assay revealed bacteriostatic and bacteriocidal mechanisms in different members of this set of compounds, raising the possibility of more than one biological target. The observed antimicrobial activity and MraY inhibition shown by peptidomimetic compounds confirms that this site could be targeted by drug-like molecules.
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Affiliation(s)
- Rachel V Kerr
- Department of Chemistry, University of Warwick, Coventry CV4 7AL, UK
| | - Julia A Fairbairn
- Department of Chemistry, University of Warwick, Coventry CV4 7AL, UK
| | - Andrew T Merritt
- LifeArc, SBC Open Innovation Campus, Stevenage, Herts SG1 2FX, UK
| | - Timothy D H Bugg
- Department of Chemistry, University of Warwick, Coventry CV4 7AL, UK.
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Wesseling CMJ, Slingerland CJ, Veraar S, Lok S, Martin NI. Structure-Activity Studies with Bis-Amidines That Potentiate Gram-Positive Specific Antibiotics against Gram-Negative Pathogens. ACS Infect Dis 2021; 7:3314-3335. [PMID: 34766746 PMCID: PMC8669655 DOI: 10.1021/acsinfecdis.1c00466] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
![]()
Pentamidine, an FDA-approved
antiparasitic drug, was recently identified
as an outer membrane disrupting synergist that potentiates erythromycin,
rifampicin, and novobiocin against Gram-negative bacteria. The same
study also described a preliminary structure–activity relationship
using commercially available pentamidine analogues. We here report
the design, synthesis, and evaluation of a broader panel of bis-amidines
inspired by pentamidine. The present study both validates the previously
observed synergistic activity reported for pentamidine, while further
assessing the capacity for structurally similar bis-amidines to also
potentiate Gram-positive specific antibiotics against Gram-negative
pathogens. Among the bis-amidines prepared, a number of them were
found to exhibit synergistic activity greater than pentamidine. These
synergists were shown to effectively potentiate the activity of Gram-positive
specific antibiotics against multiple Gram-negative pathogens such
as Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas
aeruginosa, and Escherichia coli, including polymyxin- and carbapenem-resistant strains.
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Affiliation(s)
- Charlotte M. J. Wesseling
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
| | - Cornelis J. Slingerland
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
| | - Shanice Veraar
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
| | - Samantha Lok
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
| | - Nathaniel I. Martin
- Biological Chemistry Group, Institute of Biology Leiden, Leiden University, 2333 BE Leiden, The Netherlands
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4
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Ferreira A, Martins H, Oliveira JC, Lapa R, Vale N. In Silico Pharmacokinetic Study of Vancomycin Using PBPK Modeling and Therapeutic Drug Monitoring. Curr Drug Metab 2021; 22:150-162. [PMID: 33397252 DOI: 10.2174/1389200221999210101232417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/19/2020] [Accepted: 09/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Vancomycin has been in clinical use for nearly 50 years and remains the first-line treatment option for Gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA). There are multiple strategies to monitor therapy and adjust the dose of this antibiotic. AUC24/MIC ratio has been demonstrated to be the best parameter to predict the effectiveness and safety of vancomycin, and a target ratio of ≥400 is recommended. Still, trough and peak serum levels at steady-state conditions have been used in clinical settings as an accurate and practical method to monitor vancomycin. METHODS In this work, we collected and analyzed clinical information of patients being treated in a hospital center in Porto (Portugal) and studied the pharmacokinetics of vancomycin in silico, developing several physiologically based pharmacokinetic (PBPK) models using simulation software GastroPlus™. Different dosages and treatment regimens were studied, and the influence of patients' age, weight and renal function was evaluated; a simulation population was also performed. RESULTS A linear effect of dose and a significant influence of weight and renal function in plasmatic levels of vancomycin was observed. CONCLUSION The results of this work corroborate the accumulation of vancomycin in plasma and identify some parameters that influence the pharmacokinetics of this antibiotic. The importance of therapeutic monitoring of vancomycin is highlighted, and the usefulness of in silico tools, namely PBPK modeling, is demonstrated.
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Affiliation(s)
- Abigail Ferreira
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Dr. Placido da Costa, 4200-450 Porto, Portugal
| | - Helena Martins
- Departament of Pathology, Clinical Chemistry Service, Centro Hospitalar Universitário do Porto (CHUP), Largo Prof. Abel Salazar 4099-001, Porto, Portugal
| | - José C Oliveira
- Departament of Pathology, Clinical Chemistry Service, Centro Hospitalar Universitário do Porto (CHUP), Largo Prof. Abel Salazar 4099-001, Porto, Portugal
| | - Rui Lapa
- LAQV/REQUIMTE, Laboratory of Applied Chemistry, Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, Rua de Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Dr. Placido da Costa, 4200-450 Porto, Portugal
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5
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Wong PN, Mak SK, Lee KF, Fung LH, Wong AK. A Prospective Study of Vancomycin(Vancoled-) Induced Chemical Peritonitis in Capd Patients. Perit Dial Int 2020. [DOI: 10.1177/089686089701700220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ping-Nam Wong
- Renal Unit Department of Medicine Kwong Wah Hospital Hong Kong
| | - Siu-Ka Mak
- Renal Unit Department of Medicine Kwong Wah Hospital Hong Kong
| | - Ka-Fai Lee
- Renal Unit Department of Medicine Kwong Wah Hospital Hong Kong
| | - Lewis H. Fung
- Renal Unit Department of Medicine Kwong Wah Hospital Hong Kong
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6
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Wang AY, Li PK, Lai KN. Comparison of Intraperitoneal Administration of Two Preparations of Vancomycin in Causing Chemical Peritonitis. Perit Dial Int 2020. [DOI: 10.1177/089686089601600215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Angela Y.M. Wang
- Department of Medicine Prince of Wales Hospital Chinese University of Hong Kong Hong Kong
| | - Philip K.T. Li
- Department of Medicine Prince of Wales Hospital Chinese University of Hong Kong Hong Kong
| | - Kar N. Lai
- Department of Medicine Prince of Wales Hospital Chinese University of Hong Kong Hong Kong
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7
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Sakamoto Y, Ochiai H, Ohsugi I, Inoue Y, Yoshimura Y, Kishi K. Evaluation of antibiotic-loaded calcium phosphate bone cement in an cranium-infected experimental model. Neurol Med Chir (Tokyo) 2014; 54:647-53. [PMID: 24670313 PMCID: PMC4533499 DOI: 10.2176/nmc.oa.2013-0295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Treatment of calvarial defects has remained a challenge in reconstruction surgery, especially because of infection at these sites. We produced a bactericidal biomaterial for treating infected bone defects by using calcium phosphate bone cement mixed with antibiotics. We evaluated the usefulness of this material mixed with the antibiotic vancomycin in a cranium-infected rat model. The concentration of vancomycin used was 5.0 wt%, as reported in our previous study. In order to establish the rat model, a cranium defect (diameter, 5 mm) was made that was infected with methicillin-resistant Staphylococcus aureus (MRSA). Thirty-six rats were divided into 6 groups depending on whether an autologous graft or bone cement with or without antibiotic was used for the defect. After 1 and 4 weeks, abscess formation was checked, tissue bacterial counts were determined, and pathological examination was performed. At both 1 and 4 weeks, no MRSA was detected on tissue bacterial culture or pathological examination in groups that received bone cement with antibiotics. In groups that received bone cement without antibiotic, MRSA was detected, and the bone cement had compromised and disintegrated into several slices. In conclusion, bone cement that contains antibiotics appears to be effective not only for reconstruction in cases of cranial defect, but also in terms of preventing infection.
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Affiliation(s)
- Yoshiaki Sakamoto
- Department of Plastic and Reconstructive Surgery, Keio University School of Medicine
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8
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Nitanai Y, Kikuchi T, Kakoi K, Hanamaki S, Fujisawa I, Aoki K. Crystal Structures of the Complexes between Vancomycin and Cell-Wall Precursor Analogs. J Mol Biol 2009; 385:1422-32. [DOI: 10.1016/j.jmb.2008.10.026] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 10/06/2008] [Accepted: 10/08/2008] [Indexed: 11/29/2022]
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9
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Rubio-Martínez LM, López-Sanromán J, Cruz AM, Santos M, Andrés MS, Román FS. Evaluation of safety and pharmacokinetics of vancomycin after intravenous regional limb perfusion in horses. Am J Vet Res 2005; 66:2107-13. [PMID: 16379655 DOI: 10.2460/ajvr.2005.66.2107] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate clinical variables, regional concentrations, and pharmacokinetics of vancomycin in the synovial fluid of distal forelimb joints of horses after IV regional limb perfusion. ANIMALS 6 horses. PROCEDURE Vancomycin was administered via IV regional limb perfusion to the distal portion of the forelimbs of anesthetized horses. Drug (300 mg of vancomycin hydrochloride in 60 mL of saline [0.9% NaCl] solution) was infused into 1 forelimb, whereas the contralateral limb served as a control and was perfused with 60 mL of saline solution. Solutions were injected into the lateral digital vein after digital exsanguination. Synovial fluid from the metacarpophalangeal (MTCP) and distal interphalangeal (DIP) joints and systemic blood were collected prior to perfusion and 15, 30, 45, 65, and 90 minutes after initiation of the infusion. Synovial fluid from the MTCP joint and blood were also obtained at 4, 8, 12, and 24 hours after infusion. Plasma urea and creatinine concentrations, degree of lameness, and certain clinical variables involving the MTCP joint and infusion site were assessed for 7 days. Results were compared between the vancomycin treatment and control groups. RESULTS No complications or significant differences in renal function, lameness, or clinical variables were observed between groups. Vancomycin concentrations exceeded 4 microg/mL in MTCP joints for approximately 20 hours. Higher concentrations were reached in DIP joints than in MTCP joints. CONCLUSIONS AND CLINICAL RELEVANCE IV regional limb perfusion with 300 mg of vancomycin as a 0.5% solution was safe and may be useful in horses as treatment for distal limb infections.
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Affiliation(s)
- Luis M Rubio-Martínez
- Department of Animal Medicine and Surgery, Faculty of Veterinary Medicine, Complutense University of Madrid, Avenida Puerta de Hierro SN, 28040 Madrid, Spain
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10
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Nicolaou KC, Cho SY, Hughes R, Winssinger N, Smethurst C, Labischinski H, Endermann R. Solid- and solution-phase synthesis of vancomycin and vancomycin analogues with activity against vancomycin-resistant bacteria. Chemistry 2001; 7:3798-823. [PMID: 11575782 DOI: 10.1002/1521-3765(20010903)7:17<3798::aid-chem3798>3.0.co;2-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Vancomycin, the prototypical member of the glycopeptide family of antibiotics, is a clinically used antibiotic employed against a variety of drug-resistant bacterial strains including methicillin-resistant Staphylococcus aureus (MRSA). The recent emergence of vancomycin resistance, viewed as a growing threat to public health, prompted us to initiate a program aimed at restoring the potency of this important antibiotic through chemical manipulation of the vancomycin structure. Herein, we describe the development of synthetic technology based on the design of a novel selenium safety catch linker, application of this technology to a solid-phase semisynthesis of vancomycin, and the solid- and solution-phase synthesis of vancomycin libraries. Biological evaluation of these compound libraries led to the identification of a number of in vitro highly potent antibacterial agents effective against vancomycin-resistant bacteria. In addition to aiding these investigations, the solid-phase chemistry described herein is expected to enhance the power of combinatorial chemistry and facilitate chemical biology and medicinal chemistry studies.
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Affiliation(s)
- K C Nicolaou
- Department of Chemistry and The Skaggs Institute for Chemical Biology, La Jolla, California 92037, USA.
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11
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Wrishko RE, Levine M, Khoo D, Abbott P, Hamilton D. Vancomycin pharmacokinetics and Bayesian estimation in pediatric patients. Ther Drug Monit 2000; 22:522-31. [PMID: 11034256 DOI: 10.1097/00007691-200010000-00004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The vancomycin pharmacokinetic profile was characterized in six pediatric patients and the potential of nonlinear mixed effects modeling and Bayesian forecasting for vancomycin monitoring was explored using NONMEM V (1.1). Based on steady state serial vancomycin concentrations, the estimates of mean t1/2, Vd, and Cl derived by the Sawchuk and Zaske method (1) were 3.52 hours, 0.57 L/kg, and 0.12 L/h per kg, respectively. NONMEM analysis demonstrated that a weight-adjusted two-compartment model described individual patients' data better than a comparable one-compartment model. The two-compartment estimates of mean t1/2alpha, t1/2beta, Vss, and Cl were 0.80 hour, 5.63 hours, 0.63 L/kg, and 0.11 L/h per kg, respectively. The relatively long mean t1/2alpha suggests that peak vancomycin concentrations measured earlier than 4 hours postdose do not reflect postdistributional serum concentrations. NONMEM population modeling revealed that a weight-adjusted two-compartment model provided a better fit than a comparable one-compartment model. The resulting population parameters and variances were fixed in NONMEM to obtain Bayesian predictions of individual vancomycin serum concentrations. Bayesian estimation with either a single midinterval or trough sample has the potential to provide accurate and precise predictions of vancomycin concentrations. This should be evaluated using a vancomycin population pharmacokinetic model based on a larger sample of pediatric patients.
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Affiliation(s)
- R E Wrishko
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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13
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Abstract
Recognized since 1883 as a common cause of infection, Staphylococcus aureus' preantimicrobial-era bacteremia mortality rate was 82%. The mortality of that era threatens to return as evidence of growing vancomycin resistance undermines the utility of vancomycin therapy. Successful treatment of S. aureus infections requires knowledge of its antimicrobial resistance capacity.
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Affiliation(s)
- T L Smith
- Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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15
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Antibiotics for treatment of infections caused by MRSA and elimination of MRSA carriage. What are the choices? Int J Antimicrob Agents 1997; 9:1-19. [DOI: 10.1016/s0924-8579(97)00027-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/1997] [Indexed: 11/15/2022]
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16
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Schmidt J, Pollack CV. Antibiotic use in the emergency department. III. The quinolones, new beta lactams, beta lactam combination agents, and miscellaneous antibiotics. J Emerg Med 1996; 14:483-96. [PMID: 8842923 DOI: 10.1016/0736-4679(96)00085-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article reviews several new, relatively broad-spectrum antibiotics that have utility in the emergency department (ED). The quinolones have excellent activity against gram-negative organisms, including gonococcus, and are characterized by very high bioavailability after oral administration. The new beta-lactams aztreonam and imipenem have broad spectra but limited usefulness to the emergency physician, and should be reserved for judicious use in severe infections, particularly those involving Pseudomonas. Clavulanate, sulbactam, and tazobactam are themselves antimicrobials that have been combined with beta-lactams such as ampicillin and ticarcillin to produce agents with significant potential utility in the ED; these are typically not first-line agents, however, and their use should be governed by both clinical and cost concerns. Finally, three older antibiotics--vancomycin, metronidazole, and clindamycin--are reviewed with respect to updated indications for their use in the ED.
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Affiliation(s)
- J Schmidt
- Department of Emergency Medicine, Maricopa Medical Center, Phoenix, Arizona 85008, USA
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17
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Abstract
Vancomycin is a nontoxic glycopeptide antibiotic most often used to treat serious gram-positive infections, C. difficile diarrhea/colitis, and endocarditis and hemodialysis shunt prophylaxis. Vancomycin should not be added to drug regimens for gram-positive coverage, and the empiric use of vancomycin should be discouraged to avoid the emergence of VRE. Vancomycin serum levels are no longer necessary or cost effective in most patients because vancomycin is not nephrotoxic.
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Affiliation(s)
- B A Cunha
- Infectious Disease Division, Winthrop-University Hospital, Mineola, New York, USA
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18
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Reetze-Bonorden P, Böhler J, Keller E. Drug dosage in patients during continuous renal replacement therapy. Pharmacokinetic and therapeutic considerations. Clin Pharmacokinet 1993; 24:362-79. [PMID: 8504621 DOI: 10.2165/00003088-199324050-00002] [Citation(s) in RCA: 127] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The advantages of continuous haemofiltration and haemodialysis over intermittent haemodialysis for the treatment of acute renal failure are well recognised. In intensive care patients, 4 different continuous procedures, arteriovenous and venovenous haemofiltration (CAVH and CVVH) or haemodialysis (CAVHD and CVVHD), are employed. These effective detoxification treatments require knowledge of their influence on drug disposition. Data on kinetics of drugs during continuous treatment are scarce and limited almost exclusively to the oldest and least effective procedure (CAVH). Selected dialysis membranes may adsorb drugs, as in the case of aminoglycosides. In addition, elimination of substances with large molecular weights may vary depending on the pore size of the membrane, as in the case of vancomycin. Thus, even if drug dosages can be based on pharmacokinetic studies, selection of a dialysis membrane not studied may cause unpredictable drug concentrations. With these limitations in mind and considering the available literature on pharmacokinetics in patients with renal failure, general guidelines for drug dosage during continuous renal replacement therapy can be given. In haemofiltration, drug protein binding is the major factor determining sieving, i.e. the appearance of the drug in the ultrafiltrate. In haemodialysis, diffusion is added to ultrafiltration, and therefore the saturation of the combined dialysate and ultrafiltrate will decrease further with increasing dialysate flow rate. In continuous haemofiltration or haemodialysis the extracorporeal clearance can be calculated by multiplying the saturation value (estimated or, better, measured) with the ultrafiltrate and dialysate flow rate. Dividing the extracorporeal clearance by the total clearance (including the nonrenal clearance) gives the fraction of the dose removed due to extracorporeal elimination. Whether dosage recommendations available for anuric patients have to be modified or not can be decided on the basis of this value. In case of high nonrenal clearance, the degree of saturation is without clinical significance. Based on these considerations guidelines have been constructed for the effect of extracorporeal elimination on more than 120 different drugs commonly used in intensive care patients.
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Affiliation(s)
- P Reetze-Bonorden
- Department of Nephrology, University of Freiburg, Federal Republic of Germany
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19
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Abstract
Vancomycin has excellent activity against Gram-positive bacteria and is often selected for use in the infected burn patient. Because of multiple-compartment pharmacokinetics, vancomycin serum concentrations can decrease dramatically in a short time period following the end of an intravenous infusion. This accounts for the widely divergent recommendations for serum vancomycin peak concentrations, e.g. from 15 mg/l up to 80 mg/l, when the time for blood sampling following the end of intravenous infusion is different. It is in general not necessary to monitor vancomycin peak concentrations, not only because its toxic potential is overrated but also because potential toxicity and therapeutic efficacy are correlated with trough concentrations. Post-distribution 'peak' concentrations are generally only useful for determining the optimal dosing interval for patients with impaired renal function. A dosing and monitoring paradigm for vancomycin therapy in burned adults has been devised for burn care clinicians. It provides suggested dose and dosing intervals based on body weight and creatinine clearance, with specific recommendations for regimen modification based upon the results of trough serum concentration determinations.
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Affiliation(s)
- T L Rice
- University of Michigan College of Pharmacy, Ann Arbor
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Grabb PA, Albright AL. Intraventricular vancomycin-induced cerebrospinal fluid eosinophilia: report of two patients. Neurosurgery 1992; 30:630-4; discussion 634-5. [PMID: 1584367 DOI: 10.1227/00006123-199204000-00029] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pediatric neurosurgeons commonly instill vancomycin into the ventricles to treat shunt infections. This use for vancomycin, however, has not been studied in the laboratory to evaluate possible toxicities and side effects. We report two cases of cerebrospinal fluid eosinophilia (CSFE) secondary to the intraventricular administration of vancomycin. Two other cases of shunt infection during the same time period were treated for only 2 days with intraventricular vancomycin and did not manifest CSFE. We address the clinical problems and possible detrimental effects of CSFE in the setting of shunt infection. We propose a mechanism of vancomycin-induced mast cell degranulation and subsequent release of eosinophil chemotactic factor as a cause of CSFE. An initial dose of intraventricular vancomycin should take into account volume of distribution (ventricular size) to obtain a peak cerebrospinal fluid concentration of 20 to 30 micrograms/mL. We recommend following daily cell counts and vancomycin peak and trough levels to calculate the amount and frequency of intraventricular vancomycin required to maintain safe and effective concentrations and to monitor for CSFE.
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Affiliation(s)
- P A Grabb
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pennsylvania
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21
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Intraventricular Vancomycin-induced Cerebrospinal Fluid Eosinophila. Neurosurgery 1992. [DOI: 10.1097/00006123-199204000-00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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23
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Abstract
Although previously reported in the literature, the existence of chemical peritonitis due to vancomycin in patients on peritoneal dialysis remains controversial. We report four similar episodes of sterile peritonitis in three patients receiving intraperitoneal (IP) vancomycin. The prior report implicated a change in the brand of vancomycin preparation, from Vancocin to Vancoled, as a contributing factor. We noted the occurrence of such episodes following a switch from Vancocin to a generic preparation from Abbott Laboratories. High-performance liquid chromatographic (HPLC) profiles of the three preparations show Vancocin to have a lower level of impurities than the other two; the presence of certain contaminants in the other brands may be contributing to the clinical difference observed. We conclude that chemical peritonitis due to IP vancomycin administration does occur, and that increased awareness of this entity could allow other cases to be identified.
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Affiliation(s)
- D I Charney
- Department of Medicine, Brooke Army Medical Center, San Antonio, TX 78234-6200
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24
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Miralles R, Pedro-Botet J, Rubiés-Prat J. Chest pain--another adverse reaction to vancomycin. Chest 1990; 97:1504. [PMID: 2347247 DOI: 10.1378/chest.97.6.1504a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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25
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Leibowitz G, Golan D, Jeshurun D, Brezis M. Mononeuritis multiplex associated with prolonged vancomycin treatment. BMJ (CLINICAL RESEARCH ED.) 1990; 300:1344. [PMID: 2164433 PMCID: PMC1663027 DOI: 10.1136/bmj.300.6735.1344-b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- G Leibowitz
- Department of Medicine, Hadassah University Hospital-Mt Scopus, Jerusalem, Israel
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26
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Kacew S, Bergeron MG. Pathogenic factors in aminoglycoside-induced nephrotoxicity. Toxicol Lett 1990; 51:241-59; discussion 237-9. [PMID: 2187280 DOI: 10.1016/0378-4274(90)90067-v] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Aminoglycoside antibiotics play an integral role in antimicrobial chemotherapy. Unfortunately, these drugs are known to cause nephrotoxicity in man and experimental animals. In fact, the incidence of renal dysfunction during the course of clinical treatment with aminoglycoside antibiotics is approximately 10%. Over the past two decades the elucidation of the pathogenesis of aminoglycoside-induced nephrotoxicity has been the subject of numerous investigations. This review describes the recent theories postulated to play a role in the pathogenesis of antibiotic-induced renal damage. In particular, the importance of amino-glycoside levels in the renal cortex or at the membrane binding site is examined in detail. The relevance of antibiotic tissue levels is reflected in the ability of other drugs to modify nephrotoxicity through an alteration in renal aminoglycoside content. The role of factors including age and diet in drug-induced nephrotoxicity is described. In clinical practice, aminoglycoside antibiotics may often be with other agents. The influence of aminoglycoside interaction with other drugs including vancomycin, cephalosporins and cytotoxic drugs is examined in the light of reports that nephrotoxicity is potentiated in these situations. In addition, this review focuses on the role of infection (pyelonephritis and septicemia) and bacterial endotoxin as pathogenic factors involved in aminoglycoside nephrotoxicity. Both the direct influence of endotoxin and the indirect effects of vasoactive mediators and inflammatory processes will be discussed. A multiplicity of factors is involved in the pathogenesis of aminoglycoside-induced nephrotoxicity and these are further amplified in the presence of infection.
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Affiliation(s)
- S Kacew
- Department of Pharmacology, Faculty of Health Sciences, University of Ottawa, Ontario, Canada
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27
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Kacew S, Hewitt WR, Hook JB. Gentamicin-induced renal metabolic alterations in newborn rat kidney: lack of potentiation by vancomycin. Toxicol Appl Pharmacol 1989; 99:61-71. [PMID: 2524910 DOI: 10.1016/0041-008x(89)90111-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Daily subcutaneous administration of 20 or 100 mg/kg gentamicin for 4 days significantly decreased pyridoxal-5'-phosphate and lysosomal specific phosphatidylinositol-phospholipase C (PI-PLC) in newborn rat kidney. The fall in PI-PLC was associated with an elevation in renal phosphatidylinositol, phosphatidylserine, and phosphatidylcholine. The 100 mg/kg gentamicin dose also produced a rise in renal sphingomyelin, phosphatidylethanolamine, phosphatidylglycerol, and total phospholipid (TPL) accompanied by inhibition in the activities of Na+,K+-ATPase and alkaline phosphatase. In contrast, daily intraperitoneal injection of 100 mg/kg vancomycin for 4 days failed to markedly alter renal metabolic parameters. However, the 500 mg/kg vancomycin dose increased kidney weight, TPL, and all individual phospholipid class concentrations accompanied by inhibition of lysosomal specific PI-PLC activity and reduced pyridoxal-5'-phosphate levels. Simultaneous administration of 20 mg/kg gentamicin with either vancomycin dose resulted in renal alterations similar to those produced by gentamicin alone. Concurrent treatment with 100 mg/kg aminoglycoside and either vancomycin dose produced changes in kidney which were similar to those produced by gentamicin alone, except for a synergistic rise in PI as well as a greater fall in alkaline phosphatase and pyridoxal-5'-phosphate. Surprisingly, the concentration of gentamicin and vancomycin was less in newborn kidneys of rats receiving a simultaneous high dose of vancomycin and aminoglycoside treatment compared to levels found in animals given either antibiotic separately. The lack of potentiation of nephrotoxicity in newborns administered a combination of vancomycin and gentamicin may be due to decreased accumulation of either antibiotic in kidney.
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Affiliation(s)
- S Kacew
- Department of Pharmacology, Faculty of Health Sciences, University of Ottawa, Ontario, Canada
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