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Minichmayr IK, Dreesen E, Centanni M, Wang Z, Hoffert Y, Friberg LE, Wicha SG. Model-informed precision dosing: State of the art and future perspectives. Adv Drug Deliv Rev 2024:115421. [PMID: 39159868 DOI: 10.1016/j.addr.2024.115421] [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: 06/18/2024] [Revised: 07/19/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024]
Abstract
Model-informed precision dosing (MIPD) stands as a significant development in personalized medicine to tailor drug dosing to individual patient characteristics. MIPD moves beyond traditional therapeutic drug monitoring (TDM) by integrating mathematical predictions of dosing, and considering patient-specific factors (patient characteristics, drug measurements) as well as different sources of variability. For this purpose, rigorous model qualification is required for the application of MIPD in patients. This review delves into new methods in model selection and validation, also highlighting the role of machine learning in improving MIPD, the utilization of biosensors for real-time monitoring, as well as the potential of models integrating biomarkers for efficacy or toxicity for precision dosing. The clinical evidence of TDM and MIPD is discussed for various medical fields including infection medicine, oncology, transplant medicine, and inflammatory bowel diseases, thereby underscoring the role of pharmacokinetics/pharmacodynamics and specific biomarkers. Further research, particularly randomized clinical trials, is warranted to corroborate the value of MIPD in enhancing patient outcomes and advancing personalized medicine.
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Affiliation(s)
- I K Minichmayr
- Dept. of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - E Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - M Centanni
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Z Wang
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Y Hoffert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - L E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.
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2
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Gulyás E, Horváth IL, Engh MA, Bunduc S, Dembrovszky F, Fehérvári P, Bánvölgyi A, Csupor D, Hegyi P, Karvaly GB. Assessment of the practical impact of adjusting beta-lactam dosages based on therapeutic drug monitoring in critically ill adult patients: a systematic review and meta-analysis of randomized clinical trials and observational studies. Sci Rep 2024; 14:7793. [PMID: 38565898 PMCID: PMC10987621 DOI: 10.1038/s41598-024-58200-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 03/26/2024] [Indexed: 04/04/2024] Open
Abstract
An estimated 70% of critically ill patients receive antibiotics, most frequently beta-lactams. The pharmacokinetic properties of these substances in this patient population are poorly predictable. Therapeutic drug monitoring (TDM) is helpful in making personalized decisions in this field, but its overall impact as a clinical decision-supporting tool is debated. We aimed to evaluate the clinical implications of adjusting beta-lactam dosages based on TDM in the critically ill population by performing a systematic review and meta-analysis of available investigations. Randomized controlled trials and observational studies were retrieved by searching three major databases. The intervention group received TDM-guided beta-lactam treatment, that is, at least one dose reconsideration based on the result of the measurement of drug concentrations, while TDM-unadjusted dosing was employed in the comparison group. The outcomes were evaluated using forest plots with random-effects modeling and subgroup analysis. Eight eligible studies were identified, including 1044 patients in total. TDM-guided beta-lactam treatment was associated with improved clinical cure from infection [odds ratio (OR): 2.22 (95% confidence interval (CI): 1.78-2.76)] and microbiological eradication [OR: 1.72 (CI: 1.05-2.80)], as well as a lower probability of treatment failure [OR: 0.47 (CI: 0.36-0.62)], but the heterogeneity of studies was remarkably high, especially in terms of mortality (70%). The risk of bias was moderate. While the TDM-guided administration of beta-lactams to critically ill patients has a favorable impact, standardized study designs and larger sample sizes are required for developing evidence-based protocols in this field.
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Affiliation(s)
- Eszter Gulyás
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
- Department of Laboratory Medicine, Semmelweis University, 4 Nagyvarad ter, Budapest, 1089, Hungary
| | - István László Horváth
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- University Pharmacy Department of Pharmacy Administration, Semmelweis University, Budapest, Hungary
| | - Marie Anne Engh
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Stefania Bunduc
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Fundeni Clinical Institute, Bucharest, Romania
| | - Fanni Dembrovszky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- First Department of Medicine, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - András Bánvölgyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Dermatology, Venereology and Dermatooncology, Semmelweis University, Budapest, Hungary
| | - Dezső Csupor
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Department of Clinical Pharmacy, University of Szeged, Szeged, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Center, University of Pécs, Pécs, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Gellért Balázs Karvaly
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.
- Department of Laboratory Medicine, Semmelweis University, 4 Nagyvarad ter, Budapest, 1089, Hungary.
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3
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Cafaro A, Stella M, Mesini A, Castagnola E, Cangemi G, Mattioli F, Baiardi G. Dose optimization and target attainment of vancomycin in children. Clin Biochem 2024; 125:110728. [PMID: 38325652 DOI: 10.1016/j.clinbiochem.2024.110728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 02/09/2024]
Abstract
Vancomycin is a glycopeptide antibiotic that has been adopted in clinical practice to treat gram-positive infections for more than 70 years. Despite vancomycin's long history of therapeutic use, optimal dose adjustments and pharmacokinetic/pharmacodynamic (PK/PD) target attainment in children are still under debate. Therapeutic drug monitoring (TDM) has been widely integrated into pediatric clinical practice to maximize efficacy and safety of vancomycin treatment. Area under the curve (AUC)-guided TDM has been recently recommended instead of trough-only TDM to ensure PK/PD target attainment of AUC0-24h/minimal inhibitory concentration (MIC) > 400 to 600 and minimize acute kidney injury risk. Bayesian forecasting in pediatric patients allows estimation of population PK to accurately predict individual vancomycin concentrations over time, and consequently total vancomycin exposure. AUC-guided TDM for vancomycin, preferably with Bayesian forecasting, is therefore suggested for all pediatric age groups and special pediatric populations. In this review we aim to analyze the current literature on the pediatric use of vancomycin and summarize the current knowledge on dosing optimization for target attainment in special patient populations.
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Affiliation(s)
- Alessia Cafaro
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina, Gaslini, Genova, Italy
| | - Manuela Stella
- UOC Servizio di Sperimentazioni Cliniche Pediatriche, IRCCS Istituto Giannina Gaslini, Genova, Italy; Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genova, Italy
| | - Alessio Mesini
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuliana Cangemi
- Chromatography and Mass Spectrometry Section, Central Laboratory of Analysis, IRCCS Istituto Giannina, Gaslini, Genova, Italy.
| | - Francesca Mattioli
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genova, Italy; Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genova, Italy
| | - Giammarco Baiardi
- Department of Internal Medicine, Pharmacology & Toxicology Unit, University of Genoa, Genova, Italy; Clinical Pharmacology Unit, Ente Ospedaliero Ospedali Galliera, Genova, Italy
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4
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Codina MS, Bozkir HÖ, Jorda A, Zeitlinger M. Individualised antimicrobial dose optimisation: a systematic review and meta-analysis of randomised controlled trials. Clin Microbiol Infect 2023:S1198-743X(23)00134-9. [PMID: 36965694 DOI: 10.1016/j.cmi.2023.03.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/28/2023] [Accepted: 03/14/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Therapeutic drug management (TDM) and model-informed precision dosing (MIPD) allow dose individualisation to increase drug effectivity and reduce toxicity. OBJECTIVES Evaluate the available evidence on the clinical efficacy of individualised antimicrobial dosing optimisation. METHODS Data sources: Pubmed, Embase, Web of Science, and Cochrane Library databases from database inception to the 11th of November 2022. STUDY ELIGIBILITY CRITERIA Published peer-reviewed Randomised Controlled Trials (RCTs). PARTICIPANTS Human subjects aged ≥18 years receiving an antibiotic or antifungal drug. INTERVENTIONS Patients receiving individualised antimicrobial dose adjustment. Assessment of risk of bias: Cochrane risk-of-bias tool for randomised trials (RoB2). Methods of data synthesis: Primary outcome was the risk of mortality. Secondary outcomes included target attainment, treatment failure, clinical and microbiological cure, length of stay, treatment duration and adverse events. Effect sizes were pooled using a random-effects model. Statistical heterogeneity was assessed by inconsistency testing (I2). RESULTS Ten RCTs were included in the meta-analysis (1,241 participants; n= 624 in the TDM group, n = 617 in the control group). Individualised antimicrobial dose optimisation was associated with a numerical decrease in mortality (RR = 0.86; 95% CI 0.71-1.05), without reaching statistical significance. Moreover, it was associated with significantly higher target attainment rates (RR = 1.41; 95% CI, 1.13-1.76) and a significant decrease in treatment failure (RR = 0.70; 95% CI, 0.54-0.92). Individualised antimicrobial dose optimisation was also associated with improvement, but not significant in clinical cure (RR = 1.33; 95% CI, 0.94-1.33) and microbiological outcome (RR = 1.25; CI, 1.00-1.57), as well as with a significant decrease in the risk of nephrotoxicity (RR = 0.55; 95% CI, 0.31-0.97). CONCLUSIONS This meta-analysis demonstrates that target attainment, treatment failure, and nephrotoxicity were significantly improved in patients who underwent individualised antimicrobial dose optimisation. However, it did not show a significant decrease in mortality, clinical cure or microbiological outcome.
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Affiliation(s)
- Maria Sanz Codina
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Haktan Övul Bozkir
- Department of Nutritional Sciences, University of Vienna, Vienna, Austria
| | - Anselm Jorda
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.
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5
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Kallee S, Scharf C, Schatz LM, Paal M, Vogeser M, Irlbeck M, Zander J, Zoller M, Liebchen U. Systematic Evaluation of Voriconazole Pharmacokinetic Models without Pharmacogenetic Information for Bayesian Forecasting in Critically Ill Patients. Pharmaceutics 2022; 14:pharmaceutics14091920. [PMID: 36145667 PMCID: PMC9505877 DOI: 10.3390/pharmaceutics14091920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Voriconazole (VRC) is used as first line antifungal agent against invasive aspergillosis. Model-based approaches might optimize VRC therapy. This study aimed to investigate the predictive performance of pharmacokinetic models of VRC without pharmacogenetic information for their suitability for model-informed precision dosing. Seven PopPK models were selected from a systematic literature review. A total of 66 measured VRC plasma concentrations from 33 critically ill patients was employed for analysis. The second measurement per patient was used to calculate relative Bias (rBias), mean error (ME), relative root mean squared error (rRMSE) and mean absolute error (MAE) (i) only based on patient characteristics and dosing history (a priori) and (ii) integrating the first measured concentration to predict the second concentration (Bayesian forecasting). The a priori rBias/ME and rRMSE/MAE varied substantially between the models, ranging from −15.4 to 124.6%/−0.70 to 8.01 mg/L and from 89.3 to 139.1%/1.45 to 8.11 mg/L, respectively. The integration of the first TDM sample improved the predictive performance of all models, with the model by Chen (85.0%) showing the best predictive performance (rRMSE: 85.0%; rBias: 4.0%). Our study revealed a certain degree of imprecision for all investigated models, so their sole use is not recommendable. Models with a higher performance would be necessary for clinical use.
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Affiliation(s)
- Simon Kallee
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Christina Scharf
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Lea Marie Schatz
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster, 48149 Muenster, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Johannes Zander
- Laboratory Dr. Brunner, Luisenstr. 7e, 78464 Konstanz, Germany
| | - Michael Zoller
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Uwe Liebchen
- Department of Anesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany
- Correspondence: ; Tel.: +49-89-4400-1681160
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6
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Xu J, Zhu Y, Niu P, Liu Y, Li D, Jiang L, Shi D. Establishment and application of population pharmacokinetics model of vancomycin in infants with meningitis. Pediatr Neonatol 2022; 63:57-65. [PMID: 34544677 DOI: 10.1016/j.pedneo.2021.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To establish a population pharmacokinetics (PPK) model of vancomycin (VCM) for dose individualization in Chinese infants with meningitis. METHODS We collected the data of 82 children with meningitis in hospital from July 2014 to June 2016. The initial vancomycin dosage regimen for children was 10 or 15 mg/kg for q12 h, q8 h or q6 h. Serum concentrations were determined by Viva-E Analyzer before and after the fifth administration. The PPK model was developed by nonlinear mixed-effect model software, assessed by the bootstrap method and then tested in 20 infant patients. RESULTS The VCM clearance (CL) was increased by body weight (WT) and decreased by blood urea nitrogen (BUN). Pharmacokinetic parameters of VCM were not influenced by co-administered drugs. The trough concentrations of VCM were accurately predicted by the PPK model, with the prediction errors less than 32%. CONCLUSION A new individual strategy for VCM regimens was proposed and validated by the PPK model.
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Affiliation(s)
- Jianwen Xu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China; Department of Pharmacy, Affiliated First Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Yanting Zhu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Peiguang Niu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Ying Liu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Danyun Li
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Li Jiang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China
| | - Daohua Shi
- Department of Pharmacy, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, 350001, China.
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7
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Optimizing antimicrobial use: challenges, advances and opportunities. Nat Rev Microbiol 2021; 19:747-758. [PMID: 34158654 DOI: 10.1038/s41579-021-00578-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 02/06/2023]
Abstract
An optimal antimicrobial dose provides enough drug to achieve a clinical response while minimizing toxicity and development of drug resistance. There can be considerable variability in pharmacokinetics, for example, owing to comorbidities or other medications, which affects antimicrobial pharmacodynamics and, thus, treatment success. Although current approaches to antimicrobial dose optimization address fixed variability, better methods to monitor and rapidly adjust antimicrobial dosing are required to understand and react to residual variability that occurs within and between individuals. We review current challenges to the wider implementation of antimicrobial dose optimization and highlight novel solutions, including biosensor-based, real-time therapeutic drug monitoring and computer-controlled, closed-loop control systems. Precision antimicrobial dosing promises to improve patient outcome and is important for antimicrobial stewardship and the prevention of antimicrobial resistance.
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8
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Zhao W, Wu YE, van den Anker J. Editorial: Model-Based Evaluation of Antimicrobial Agents in Children. Front Pharmacol 2021; 12:731209. [PMID: 34483942 PMCID: PMC8415744 DOI: 10.3389/fphar.2021.731209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/04/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wei Zhao
- Key Laboratory of Chemical Biology (Ministry of Education), Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Clinical Pharmacy, Clinical Trial Center, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yue-E Wu
- Key Laboratory of Chemical Biology (Ministry of Education), Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Departments of Pediatrics, Pharmacology and Physiology, Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.,Departments of Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.,Department of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
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9
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Optimizing Antimicrobial Drug Dosing in Critically Ill Patients. Microorganisms 2021; 9:microorganisms9071401. [PMID: 34203510 PMCID: PMC8305961 DOI: 10.3390/microorganisms9071401] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 12/23/2022] Open
Abstract
A fundamental step in the successful management of sepsis and septic shock is early empiric antimicrobial therapy. However, for this to be effective, several decisions must be addressed simultaneously: (1) antimicrobial choices should be adequate, covering the most probable pathogens; (2) they should be administered in the appropriate dose, (3) by the correct route, and (4) using the correct mode of administration to achieve successful concentration at the infection site. In critically ill patients, antimicrobial dosing is a common challenge and a frequent source of errors, since these patients present deranged pharmacokinetics, namely increased volume of distribution and altered drug clearance, which either increased or decreased. Moreover, the clinical condition of these patients changes markedly over time, either improving or deteriorating. The consequent impact on drug pharmacokinetics further complicates the selection of correct drug schedules and dosing during the course of therapy. In recent years, the knowledge of pharmacokinetics and pharmacodynamics, drug dosing, therapeutic drug monitoring, and antimicrobial resistance in the critically ill patients has greatly improved, fostering strategies to optimize therapeutic efficacy and to reduce toxicity and adverse events. Nonetheless, delivering adequate and appropriate antimicrobial therapy is still a challenge, since pathogen resistance continues to rise, and new therapeutic agents remain scarce. We aim to review the available literature to assess the challenges, impact, and tools to optimize individualization of antimicrobial dosing to maximize exposure and effectiveness in critically ill patients.
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10
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Goutelle S, Conrad A, Pouderoux C, Braun E, Laurent F, Gagnieu MC, Cohen S, Guitton J, Valour F, Ferry T. Pharmacokinetic/Pharmacodynamic Dosage Individualization of Suppressive Beta-Lactam Therapy Administered by Subcutaneous Route in Patients With Prosthetic Joint Infection. Front Med (Lausanne) 2021; 8:583086. [PMID: 33869238 PMCID: PMC8044368 DOI: 10.3389/fmed.2021.583086] [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] [Received: 07/14/2020] [Accepted: 02/18/2021] [Indexed: 11/14/2022] Open
Abstract
Suppressive parenteral antibiotic therapy with beta-lactams may be necessary in patients with Gram-negative bone and joint infection (BJI). Subcutaneous drug administration can facilitate this therapy in outpatient setting, but there is limited information about this practice. We have developed an original approach for drug dosing in this context, based on therapeutic drug monitoring (TDM) and pharmacokinetic/pharmacodynamic (PK/PD) principles. The objective of this study was to describe our approach and its first results in a case series. We analyzed data from patients who received suppressive antibiotic therapy by subcutaneous (SC) route with beta-lactams as salvage therapy for prosthetic joint infection (PJI) and had TDM with PK/PD-based dose adjustment. Ten patients (six women and four men with a mean age of 77 years) were included from January 2017 to May 2020. The drugs administered by SC route were ceftazidime (n = 4), ertapenem (n = 4), and ceftriaxone (n = 2). In each patient, PK/PD-guided dosage individualization was performed based on TDM and minimum inhibitory concentration (MIC) measurements. The dose interval could be prolonged from twice daily to thrice weekly in some patients, while preserving the achievement of PK/PD targets. The infection was totally controlled by the strategy in nine out the 10 patients during a median follow-up of 1,035 days (~3 years). No patient acquired carbapenem-resistant Gram-negative bacteria during the follow-up. One patient presented treatment failure with acquired drug resistance under therapy, which could be explained by late MIC determination and insufficient exposure, retrospectively. To conclude, our innovative approach, based on model-based TDM, MIC determination, and individualized PK/PD goals, facilitates, and optimizes suppressive outpatient beta-lactam therapy administered by SC route for PJI. These encouraging results advocate for larger clinical evaluation.
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Affiliation(s)
- Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France.,Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Univ Lyon, Université Lyon 1, UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Villeurbanne, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France
| | - Anne Conrad
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Cécile Pouderoux
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Evelyne Braun
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Frédéric Laurent
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France.,Institut des Agents Infectieux, Laboratoire de bactériologie, Centre National de référence des staphylocoques, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Marie-Claude Gagnieu
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Sabine Cohen
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Jérôme Guitton
- Univ Lyon, Université Lyon 1, ISPB, Faculté de Pharmacie de Lyon, Lyon, France.,Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie-Toxicologie, Lyon, France
| | - Florent Valour
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Tristan Ferry
- Centre interrégional de référence pour la prise en charge des infections ostéo-articulaires complexes (CRIOAc Lyon), Hospices Civils de Lyon, Lyon, France.,Service des maladies infectieuses et tropicales, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France.,Université Claude Bernard Lyon 1, Lyon, France.,CIRI-Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
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11
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Kim SM, Lee HS, Hwang NY, Kim K, Park HD, Lee SY. Individualized Vancomycin Dosing with Therapeutic Drug Monitoring and Pharmacokinetic Consultation Service: A Large-Scale Retrospective Observational Study. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:423-440. [PMID: 33692613 PMCID: PMC7939511 DOI: 10.2147/dddt.s285488] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/19/2021] [Indexed: 12/12/2022]
Abstract
Background To date, outcome data with a large sample size and data regarding the clinical outcomes of pharmacokinetic-guided (PK) dosing of vancomycin are limited. Aim We evaluated the pharmacokinetic and clinical outcomes of a PK-guided dosing advisory program, pharmacokinetic consultation service (PKCS), in vancomycin treatment. Methods We investigated vancomycin therapeutic drug monitoring (TDM) and PKCS use through a retrospective review of patients who had serum vancomycin trough concentration data from October 2017 to November 2018. Among these patients, we selected non-critically ill adult patients satisfying our selection criteria to evaluate the effect of PKCS. Target trough attainment rate, time to target attainment, vancomycin-induced nephrotoxicity (VIN), vancomycin treatment failure rate, and duration of vancomycin therapy were compared between patients whose dosing was adjusted according to PKCS (PKCS group), and those whose dose was adjusted at the discretion of the attending physician (non-PKCS group). Results A total of 280 patients met the selection criteria for the VIN analysis (PKCS, n=134; non-PKCS, n=146). The incidence of VIN was similar between the two groups (PKCS, n=5; non-PKCS, n=5); however, the target attainment rate was higher in the PKCS group (75% vs 60%, P = 0.012). The time to target attainment was similar between the two groups. Further exclusions yielded 112 patients for the clinical outcome evaluation (PKCS, n=51; non-PKCS, n=61). The treatment failure rate was similar, and the duration of vancomycin therapy was longer in the PKCS group (12 vs 8 days, P = 0.008). Conclusion In non-critically ill patients, an increase in target trough achieved by PKCS did not lead to decreased vancomycin treatment failures, shorter vancomycin treatment, or decreased nephrotoxicity in vancomycin treatment. Considering the excessive amount of effort currently put into vancomycin dosing and monitoring, more selective criteria for individualized pharmacokinetic-guided dosing needs to be applied.
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Affiliation(s)
- Sang-Mi Kim
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun-Seung Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Na-Young Hwang
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Kyunga Kim
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, Korea
| | - Hyung-Doo Park
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo-Youn Lee
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Clinical Pharmacology & Therapeutics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Health Science and Technology, Samsung Advanced Institute of Health Science and Technology, Sungkyunkwan University, Seoul, Korea
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12
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Willems J, Hermans E, Schelstraete P, Depuydt P, De Cock P. Optimizing the Use of Antibiotic Agents in the Pediatric Intensive Care Unit: A Narrative Review. Paediatr Drugs 2021; 23:39-53. [PMID: 33174101 PMCID: PMC7654352 DOI: 10.1007/s40272-020-00426-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 02/08/2023]
Abstract
Antibiotics are one of the most prescribed drug classes in the pediatric intensive care unit, yet the incidence of inappropriate antibiotic prescribing remains high in critically ill children. Optimizing the use of antibiotics in this population is imperative to guarantee adequate treatment, avoid toxicity and the occurrence of antibiotic resistance, both on a patient level and on a population level. Antibiotic stewardship encompasses all initiatives to promote responsible antibiotic usage and the PICU represents a major target environment for antibiotic stewardship programs. This narrative review provides a summary of the available knowledge on the optimal selection, duration, dosage, and route of administration of antibiotic treatment in critically ill children. Overall, more scientific evidence on how to optimize antibiotic treatment is warranted in this population. We also give our personal expert opinion on research priorities.
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Affiliation(s)
- Jef Willems
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium
| | - Eline Hermans
- Department of Pediatrics, Ghent University Hospital, Gent, Belgium
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium
| | - Petra Schelstraete
- Department of Pediatric Pulmonology, Ghent University Hospital, Gent, Belgium
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, Gent, Belgium
| | - Pieter De Cock
- Department of Pediatric Intensive Care, Ghent University Hospital, Gent, Belgium.
- Heymans Institute of Pharmacology, Ghent University, Gent, Belgium.
- Department of Pharmacy, Ghent University Hospital, Gent, Belgium.
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13
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Abdulla A, Edwina EE, Flint RB, Allegaert K, Wildschut ED, Koch BCP, de Hoog M. Model-Informed Precision Dosing of Antibiotics in Pediatric Patients: A Narrative Review. Front Pediatr 2021; 9:624639. [PMID: 33708753 PMCID: PMC7940353 DOI: 10.3389/fped.2021.624639] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/03/2021] [Indexed: 12/17/2022] Open
Abstract
Optimal pharmacotherapy in pediatric patients with suspected infections requires understanding and integration of relevant data on the antibiotic, bacterial pathogen, and patient characteristics. Because of age-related physiological maturation and non-maturational covariates (e.g., disease state, inflammation, organ failure, co-morbidity, co-medication and extracorporeal systems), antibiotic pharmacokinetics is highly variable in pediatric patients and difficult to predict without using population pharmacokinetics models. The intra- and inter-individual variability can result in under- or overexposure in a significant proportion of patients. Therapeutic drug monitoring typically covers assessment of pharmacokinetics and pharmacodynamics, and concurrent dose adaptation after initial standard dosing and drug concentration analysis. Model-informed precision dosing (MIPD) captures drug, disease, and patient characteristics in modeling approaches and can be used to perform Bayesian forecasting and dose optimization. Incorporating MIPD in the electronic patient record system brings pharmacometrics to the bedside of the patient, with the aim of a consisted and optimal drug exposure. In this narrative review, we evaluated studies assessing optimization of antibiotic pharmacotherapy using MIPD in pediatric populations. Four eligible studies involving amikacin and vancomycin were identified from 418 records. Key articles, independent of year of publication, were also selected to highlight important attributes of MIPD. Although very little research has been conducted until this moment, the available data on vancomycin indicate that MIPD is superior compared to conventional dosing strategies with respect to target attainment. The utility of MIPD in pediatrics needs to be further confirmed in frequently used antibiotic classes, particularly aminoglycosides and beta-lactams.
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Affiliation(s)
- Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Elma E Edwina
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Robert B Flint
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Division of Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Karel Allegaert
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Enno D Wildschut
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Matthijs de Hoog
- Department of Pediatric Intensive Care, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, Netherlands
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14
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Is Early Monitoring Better? Impact of Early Vancomycin Exposure on Treatment Outcomes and Nephrotoxicity in Patients with Methicillin-Resistant Staphylococcus aureus Infections. Antibiotics (Basel) 2020; 9:antibiotics9100672. [PMID: 33020463 PMCID: PMC7601693 DOI: 10.3390/antibiotics9100672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/21/2022] Open
Abstract
Optimal early vancomycin target exposure remains controversial. To clarify the therapeutic exposure range, we investigated the association between vancomycin exposure and treatment outcomes or nephrotoxicity in patients with methicillin-resistant Staphylococcus aureus (MRSA) infection. This retrospective study reviewed clinical data obtained from 131 patients with MRSA infections between January 2017 and September 2019. Clinical outcomes included treatment failure, 30-day mortality, microbiological failure, and acute kidney injury. We measured serum vancomycin levels after the first dose to 48 h and estimated vancomycin exposure using the Bayesian theorem. The minimum inhibitory concentration (MIC) of antimicrobial agents was determined using the broth microdilution method. Classification and Regression Tree analyses identified day 1 and 2 exposure thresholds associated with an increased risk of failure and nephrotoxicity. Treatment failure (27.9% vs. 33.3%) and 30-day mortality (26.6% vs. 31.74%) were numerically but not significantly reduced in patients with the area under the curve (AUC)24-48h/MICBMD ≥ 698. Patients with AUCss/MICBMD ≥ 679 exhibited a significantly increased risk of acute kidney injury (27.9% vs. 10.9%, p = 0.041). These findings indicate that AUCss/MICBMD ratios > 600 may cause nephrotoxicity. AUC/MICBMD at days 1 and 2 do not appear to be significantly associated with particular clinical outcomes, but further studies are needed.
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15
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Therapeutic drug monitoring of commonly used anti-infective agents: A nationwide cross-sectional survey of Australian hospital practices. Int J Antimicrob Agents 2020; 56:106180. [PMID: 32987102 DOI: 10.1016/j.ijantimicag.2020.106180] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/01/2020] [Accepted: 09/19/2020] [Indexed: 12/20/2022]
Abstract
When performed according to best-practice principles, therapeutic drug monitoring (TDM) can optimise anti-infective treatment and directly benefit clinical outcomes. We evaluated TDM performance and clinical decision-making for established anti-infective agents amongst Australian hospitals. A nationwide cross-sectional survey was conducted between August and September 2019. The survey consisted of multiple-choice questions regarding TDM of anti-infective agents in general as well as clinical vignettes specific to vancomycin, gentamicin and voriconazole. We sought to survey all Australian hospitals operating both in the public and private health sectors. Responses were captured from 85 unique institutions, from all Australian states and territories. Regarding guidelines, 26% of hospitals did not have endorsed guidelines to advise on the ordering, sampling and interpretation of TDM for any anti-infective agent. Admitting teams were predominantly responsible for ordering TDM (85%) and interpreting results (76%). Only 51% of hospitals had access to dose prediction software, with access generally better amongst principal referral (69%) (P = 0.01) and children's hospitals (100%) (P = 0.04). Whenever a laboratory-derived minimum inhibitory concentration (MIC) was not available to guide dosing decisions, a surrogate target MIC was assumed in 77% of hospitals. This was based on a 'worst-case' scenario infection in 11% of hospitals. The rates of clinical practice consistent with current guideline recommendations across all aspects of TDM were demonstrated to be 0% for vancomycin, 4% for gentamicin and 35% for voriconazole. At present, there is significant institutional variability in the clinical practice of TDM for anti-infective agents in Australia for established TDM drugs.
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16
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Sieg A, Pandya K, Winstead R, Evans R. Overview of Pharmacological Considerations in Extracorporeal Membrane Oxygenation. Crit Care Nurse 2019; 39:29-43. [PMID: 30936129 DOI: 10.4037/ccn2019236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation has become more widely used in recent years. Although this technology has proven to be lifesaving, it is not devoid of complications contributing to significant morbidity and mortality. Nurses who care for patients receiving extracorporeal membrane oxygenation should further their understanding of changes in medication profiles due to complex interactions with the extracorporeal membrane oxygenation circuitry. The aim of this comprehensive review is to give nurses a better understanding of analgesic, sedative, anti-infective, and anticoagulation medications that are frequently used to treat patients receiving extracorporeal membrane oxygenation.
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Affiliation(s)
- Adam Sieg
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support. .,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy. .,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia. .,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina.
| | - Komal Pandya
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Ryan Winstead
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
| | - Rickey Evans
- Adam Sieg is an assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy, Lexington, Kentucky, and a clinical pharmacist specialist in advanced heart failure and heart transplant/mechanical circulatory support.,Komal Pandya is a cardiothoracic surgery clinical pharmacist with the University of Kentucky Medical Center in Lexington, Kentucky, and adjunct assistant professor in the Department of Pharmacy Practice and Science at the University of Kentucky College of Pharmacy.,Ryan Winstead is a clinical transplant specialist at Virginia Commonwealth University Health, Richmond, Virginia.,Rickey Evans is an assistant professor in the Department of Clinical Pharmacy and Outcomes Sciences at the University of South Carolina College of Pharmacy and clinical pharmacy specialist in critical care at Palmetto Health Richland in Columbia, South Carolina
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17
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He N, Su S, Yan Y, Liu W, Zhai S. The Benefit of Individualized Vancomycin Dosing Via Pharmacokinetic Tools: A Systematic Review and Meta-analysis. Ann Pharmacother 2019; 54:331-343. [PMID: 31694384 DOI: 10.1177/1060028019887363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Various pharmacokinetic (PK) equations and software have been developed to individualize vancomycin dosing. However, the benefit of using any PK information to guide vancomycin dosing has not been fully elucidated. Objective: To appraise available evidence on the effectiveness and safety of individualized vancomycin dosing via PK tools. Methods: PubMed, EMBASE, the Cochrane Library, and 2 Chinese literature databases were searched through August 1, 2019. Randomized controlled trials (RCTs) and cohort studies that reported the PK and clinical outcomes of individualized vancomycin dosing versus empirical dosing were included. Pooled risk ratios (RRs) and mean differences were calculated for dichotomous and continuous outcomes, respectively. Results: A total of 21 studies involving 4346 patients were finally included, of which 3 were RCTs and 18 were cohort studies. Meta-analysis revealed that PK-guided vancomycin dosing significantly increased the attainment of target trough concentration (RR = 1.59; 95% CI = 1.49-1.70) and decreased the incidence of nephrotoxicity (RR = 0.57; 95% CI = 0.46-0.71). Additionally, the available evidence showed that target area under the curve/minimum inhibitory concentration attainment rate and time to target concentration could improve. However, the evidence on clinical outcomes was scarce, and no significant differences were detected in clinical response rate, microbiological eradication rate, mortality, and length of hospital stay between PK-guided vancomycin dosing and empirical dosing strategies. Conclusion and Relevance: Individualized vancomycin dosing via PK tools significantly increases the attainment of target trough concentration and decreases the incidence of nephrotoxicity. Evidence on clinical effectiveness was limited and showed no significant benefit. Further well-designed studies are warranted to assess its clinical effectiveness and inform routine care.
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Affiliation(s)
- Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Shan Su
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Yingying Yan
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Wenxi Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
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18
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Sosnin N, Curtis N, Cranswick N, Chiletti R, Gwee A. Vancomycin is commonly under-dosed in critically ill children and neonates. Br J Clin Pharmacol 2019; 85:2591-2598. [PMID: 31378957 PMCID: PMC6848905 DOI: 10.1111/bcp.14084] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/28/2019] [Accepted: 07/17/2019] [Indexed: 01/22/2023] Open
Abstract
Aims Vancomycin is frequently used in critically ill children in whom the drug pharmacokinetics are significantly altered as a result of changes in renal clearance and volume of distribution. Therapeutic drug monitoring (TDM) is recommended to achieve vancomycin trough concentrations between 10 and 20 mg/L. In this study we reviewed vancomycin dosing, TDM and treatment outcomes in paediatric and neonatal intensive care unit patients. Methods We reviewed the medical records of all patients receiving intravenous vancomycin in a tertiary paediatric and neonatal intensive care unit over a 10‐month period. Demographic, vancomycin dosing, TDM and drug‐related adverse effects data were collected. Results In total, 115 children received 126 courses of vancomycin and had at least 1 TDM blood sample taken at steady state. In only 38/126 (30%) courses was the target concentration (10–20 mg/L) achieved at the initial steady state trough sample. Of the 88 courses that had initial trough concentrations outside the target range, the dose was adjusted in only 49 (56%). Overall, minimum doses of 30 mg/kg/day in neonates with a corrected gestational age of <35 weeks, and 50 mg/kg/day in older children, were required to achieve target vancomycin concentrations. Vancomycin‐attributable nephrotoxicity occurred in 10/126 (8%) courses and there were no episodes of red man syndrome. Conclusion In critically ill children, individualised dosing is needed. In the absence of Bayesian model‐based dosing, in children with normal renal function, empiric vancomycin doses of at least 30 mg/kg/day in neonates of <35 weeks corrected gestational age, and 50 mg/kg/day in older children, should be considered. Optimisation of TDM practices through the development of protocols, ideally built into electronic medical records, should be considered.
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Affiliation(s)
- Natasha Sosnin
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Nigel Curtis
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Noel Cranswick
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Roberto Chiletti
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Amanda Gwee
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
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19
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Abstract
BACKGROUND Several studies have reported that trough levels may not be optimal for monitoring vancomycin therapy, because of overexposure and nephrotoxicity risks. Therefore, we developed a population pharmacokinetic model to optimize vancomycin dosing and monitoring in pediatrics. METHODS Data were retrospectively collected on 76 pediatric patients 1-12 years of age, admitted to general pediatric wards or intensive care units at King Saud University Medical City, Riyadh, Saudi Arabia. The predictability of 3 methods for calculating the area under the curve (AUC) at steady state was assessed for optimum vancomycin therapy monitoring. The 3 methods were simple linear regression, Bayesian approach and the 2-sample pharmacokinetic equation method. We also used Monet Carlo simulations to evaluate the dosing of vancomycin. RESULTS A 1-compartment model adequately described the data. A strong correlation occurred between the observed and predicted AUC from 0 to 24 hours (AUC0-24h) calculated using the Bayesian approach with a trough sample only or pharmacokinetic equations based on 2 measured samples (R = 0.93 and 0.92, respectively). For the simple linear regression method with a trough sample only, the predicted AUC0-24h at steady state with vancomycin trough levels of 10, 15 and 20 µg/mL were 413, 548 and 714 µg·hour/mL, respectively. The target AUC0-24h above 400 was achieved in 46% and 95% of individuals with trough values of 7-11 and 11-15 µg/mL, respectively. Monte Carlo simulations showed that 60-80 mg/kg/d doses are needed to optimize vancomycin therapy. CONCLUSIONS In conclusion, targeting vancomycin trough levels above 15 µg/mL in pediatrics would overshoot the target AUC0-24h above 400 and expose them to unnecessary adverse events.
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A Larger Dose of Vancomycin Is Required in Adult Neurosurgical Intensive Care Unit Patients Due to Augmented Clearance. Ther Drug Monit 2016; 37:609-18. [PMID: 25627406 DOI: 10.1097/ftd.0000000000000187] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to explore the pharmacokinetics of vancomycin and determine an appropriate dosage regimen for vancomycin in adult neurosurgical intensive care unit (ICU) patients. METHODS First, a 20-month therapeutic drug monitoring database at a medical center was used to retrospectively analyze the pharmacokinetic parameters of vancomycin in adult neurosurgical patients. Significant covariates were selected through Pearson or Spearman correlation tests and multiple linear regressions. Pharmacokinetic models were built using significant covariates to predict vancomycin clearance. Second, a 12-month prospective cohort of neurosurgical ICU patients was recruited to validate the models. Urine and cerebrospinal fluid samples were collected, and vancomycin concentrations were determined using a high-performance liquid chromatography assay. The relation between the model-predicted and observed pharmacokinetic parameters was assessed by Pearson correlation. RESULTS In the retrospective cohort, 98 sets of peak/trough serum concentrations obtained from 73 patients were analyzed. These patients had a mean age of 54 ± 16 years, an estimated creatinine clearance (eClCr) of 83 ± 29 mL/min, a total vancomycin clearance (ClVan) of 101 ± 41 mL/min, and a volume of distribution (Vd) of 0.93 ± 0.27 L/kg. In a subgroup analysis, the ClVan of ICU patients was higher than the ClVan of non-ICU patients (1.57 ± 0.34-fold versus 1.16 ± 0.32-fold of eClCr, P < 0.05). Fifteen patients enrolled in the prospective cohort had an average age of 67 ± 12 years, an eClCr of 108 ± 44 mL/min, a ClVan of 112 ± 29 mL/min, and a Vd of 1.03 ± 0.55 L/kg. CONCLUSIONS Adult neurosurgical ICU patients have a significantly elevated ClVan. In this study, 2 dosing equations were derived to achieve optimal serum vancomycin concentrations for this special population.
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Abstract
Therapeutic drug monitoring (TDM) aims to integrate drug measurement results into clinical decision making. The basic rules apply when using TDM in neonates (aminoglycosides, vancomycin, phenobarbital, digoxin), but additional factors should also be taken into account. First, due to both pharmacokinetic variability and non-pharmacokinetic factors, the correlation between dosage and concentration is poor in neonates, but can be overcome with the use of more complex, validated dosing regimens. Second, the time to reach steady state is prolonged, especially when no loading dose is used. Consequently, the timing of TDM sampling is important in this population. Third, the target concentration may be uncertain (vancomycin) or depend on specific factors (phenobarbital during whole body cooling). Finally, because of differences in matrix composition (eg, protein, bilirubin), assay-related inaccuracies may be different in neonates. We anticipate that complex validated dosing regimens, with subsequent TDM sampling and Bayesian forecasting, are the next step in tailoring pharmacotherapy to individual neonates.
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Affiliation(s)
- Steven Pauwels
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
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22
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Improved Tacrolimus Target Concentration Achievement Using Computerized Dosing in Renal Transplant Recipients--A Prospective, Randomized Study. Transplantation 2016; 99:2158-66. [PMID: 25886918 DOI: 10.1097/tp.0000000000000708] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early after renal transplantation, it is often challenging to achieve and maintain tacrolimus concentrations within the target range. Computerized dose individualization using population pharmacokinetic models may be helpful. The objective of this study was to prospectively evaluate the target concentration achievement of tacrolimus using computerized dosing compared with conventional dosing performed by experienced transplant physicians. METHODS A single-center, prospective study was conducted. Renal transplant recipients were randomized to receive either computerized or conventional tacrolimus dosing during the first 8 weeks after transplantation. The median proportion of tacrolimus trough concentrations within the target range was compared between the groups. Standard risk (target, 3-7 μg/L) and high-risk (8-12 μg/L) recipients were analyzed separately. RESULTS Eighty renal transplant recipients were randomized, and 78 were included in the analysis (computerized dosing (n = 39): 32 standard risk/7 high-risk, conventional dosing (n = 39): 35 standard risk/4 high-risk). A total of 1711 tacrolimus whole blood concentrations were evaluated. The proportion of concentrations per patient within the target range was significantly higher with computerized dosing than with conventional dosing, both in standard risk patients (medians, 90% [95% confidence interval {95% CI}, 84-95%] vs 78% [95% CI, 76-82%], respectively, P < 0.001) and in high-risk patients (medians, 77% [95% CI, 71-80%] vs 59% [95% CI, 40-74%], respectively, P = 0.04). CONCLUSIONS Computerized dose individualization improves target concentration achievement of tacrolimus after renal transplantation. The computer software is applicable as a clinical dosing tool to optimize tacrolimus exposure and may potentially improve long-term outcome.
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Gonçalves-Pereira J, Oliveira B. Antibiotics and extracorporeal circulation--one size does not fit all. Crit Care 2014; 18:695. [PMID: 25673035 PMCID: PMC4331389 DOI: 10.1186/s13054-014-0695-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Dosing of antibiotics in critically ill patients is a significant challenge. The increasing number of patients undergoing extracorporeal membrane oxygenation further complicates the issue due to inflammatory activation and to drug sequestration in the circuit. Since patients receiving extracorporeal membrane oxygenation commonly face severe infections, appropriate antibiotic selection and correct dosing is of paramount importance to improve survival. Therapeutic drug monitoring (whenever available) or population pharmacokinetics, based on readily available clinical and laboratory data, should help tailor antibiotic dosing to the individual patient.
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Wong G, Sime FB, Lipman J, Roberts JA. How do we use therapeutic drug monitoring to improve outcomes from severe infections in critically ill patients? BMC Infect Dis 2014; 14:288. [PMID: 25430961 PMCID: PMC4289211 DOI: 10.1186/1471-2334-14-288] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 05/23/2014] [Indexed: 11/16/2022] Open
Abstract
High mortality and morbidity rates associated with severe infections in the critically ill continue to be a significant issue for the healthcare system. In view of the diverse and unique pharmacokinetic profile of drugs in this patient population, there is increasing use of therapeutic drug monitoring (TDM) in attempt to optimize the exposure of antibiotics, improve clinical outcome and minimize the emergence of antibiotic resistance. Despite this, a beneficial clinical outcome for TDM of antibiotics has only been demonstrated for aminoglycosides in a general hospital patient population. Clinical outcome studies for other antibiotics remain elusive. Further, there is significant variability among institutions with respect to the practice of TDM including the selection of patients, sampling time for concentration monitoring, methodologies of antibiotic assay, selection of PK/PD targets as well as dose optimisation strategies. The aim of this paper is to review the available evidence relating to practices of antibiotic TDM, and describe how TDM can be applied to potentially improve outcomes from severe infections in the critically ill.
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Affiliation(s)
| | | | | | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Queensland, Australia.
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Li X, Wang F, Xu B, Yu X, Yang Y, Zhang L, Li H. Determination of the free and total concentrations of vancomycin by two-dimensional liquid chromatography and its application in elderly patients. J Chromatogr B Analyt Technol Biomed Life Sci 2014; 969:181-9. [PMID: 25178192 DOI: 10.1016/j.jchromb.2014.08.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 07/28/2014] [Accepted: 08/03/2014] [Indexed: 12/25/2022]
Abstract
A robust two-dimensional liquid chromatography (2D-LC) method for determining the free and total concentrations of vancomycin in plasma was developed and validated. The 2D-LC system, which exhibited a strong capacity for inhibiting interference, comprised a unique RP1-IEX-RP2 column system and an "Assistant Flow" configuration. Ultrafiltration technology was employed to separate free vancomycin from the protein-bound fraction in human plasma. The influence of ultrafiltration conditions on the free vancomycin concentration was evaluated. The calibration curve was linear over the 0.195-49.92μg/ml range for the free and total vancomycin concentrations. The within- and between-run precision ranges were 1.5-3.9% and 2.0-4.7% for the total concentration, 1.4-3.3% and 2.4-4.0% for the free concentration, respectively. Ultrafiltration was susceptible to variations in the experimental conditions, including the centrifugation time, the centrifugal force, and the nominal molecular weight limit of the ultrafiltration membrane. A total of 101 serum samples from 84 elderly patients were analyzed by this method. The free vancomycin concentration was 5.88±3.75μg/ml (range: 0.240-16.79μg/ml), the total concentration was 12.36±5.36μg/ml (range: 2.16-27.14μg/ml), and the unbound fraction was 45.6±18.8% (range: 11.1-96.9%). There was a poor correlation between the free and total vancomycin concentrations (R(2)=0.596, p<0.05). This method appears to be sensitive, precise, selective, and suitable for use in protein-binding studies of vancomycin.
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Affiliation(s)
- Xin Li
- Clinical Pharmaceutical Research Institute, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; The Third Hospital of Changsha, Changsha, Hunan 410015, China
| | - Feng Wang
- Clinical Pharmaceutical Research Institute, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Bin Xu
- The Third Hospital of Changsha, Changsha, Hunan 410015, China
| | - Xiaowei Yu
- The Third Hospital of Changsha, Changsha, Hunan 410015, China
| | - Yang Yang
- School of Pharmaceutical Sciences, Central South University, Changsha, Hunan 410013, China
| | - Li Zhang
- The Third Hospital of Changsha, Changsha, Hunan 410015, China
| | - Huande Li
- Clinical Pharmaceutical Research Institute, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
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Gillaizeau F, Chan E, Trinquart L, Colombet I, Walton RT, Rège-Walther M, Burnand B, Durieux P. Computerized advice on drug dosage to improve prescribing practice. Cochrane Database Syst Rev 2013; 2013:CD002894. [PMID: 24218045 PMCID: PMC11393523 DOI: 10.1002/14651858.cd002894.pub3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Maintaining therapeutic concentrations of drugs with a narrow therapeutic window is a complex task. Several computer systems have been designed to help doctors determine optimum drug dosage. Significant improvements in health care could be achieved if computer advice improved health outcomes and could be implemented in routine practice in a cost-effective fashion. This is an updated version of an earlier Cochrane systematic review, first published in 2001 and updated in 2008. OBJECTIVES To assess whether computerized advice on drug dosage has beneficial effects on patient outcomes compared with routine care (empiric dosing without computer assistance). SEARCH METHODS The following databases were searched from 1996 to January 2012: EPOC Group Specialized Register, Reference Manager; Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Ovid; EMBASE, Ovid; and CINAHL, EbscoHost. A "top up" search was conducted for the period January 2012 to January 2013; these results were screened by the authors and potentially relevant studies are listed in Studies Awaiting Classification. The review authors also searched reference lists of relevant studies and related reviews. SELECTION CRITERIA We included randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies and interrupted time series analyses of computerized advice on drug dosage. The participants were healthcare professionals responsible for patient care. The outcomes were any objectively measured change in the health of patients resulting from computerized advice (such as therapeutic drug control, clinical improvement, adverse reactions). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality. We grouped the results from the included studies by drug used and the effect aimed at for aminoglycoside antibiotics, amitriptyline, anaesthetics, insulin, anticoagulants, ovarian stimulation, anti-rejection drugs and theophylline. We combined the effect sizes to give an overall effect for each subgroup of studies, using a random-effects model. We further grouped studies by type of outcome when appropriate (i.e. no evidence of heterogeneity). MAIN RESULTS Forty-six comparisons (from 42 trials) were included (as compared with 26 comparisons in the last update) including a wide range of drugs in inpatient and outpatient settings. All were randomized controlled trials except two studies. Interventions usually targeted doctors, although some studies attempted to influence prescriptions by pharmacists and nurses. Drugs evaluated were anticoagulants, insulin, aminoglycoside antibiotics, theophylline, anti-rejection drugs, anaesthetic agents, antidepressants and gonadotropins. Although all studies used reliable outcome measures, their quality was generally low.This update found similar results to the previous update and managed to identify specific therapeutic areas where the computerized advice on drug dosage was beneficial compared with routine care:1. it increased target peak serum concentrations (standardized mean difference (SMD) 0.79, 95% CI 0.46 to 1.13) and the proportion of people with plasma drug concentrations within the therapeutic range after two days (pooled risk ratio (RR) 4.44, 95% CI 1.94 to 10.13) for aminoglycoside antibiotics;2. it led to a physiological parameter more often within the desired range for oral anticoagulants (SMD for percentage of time spent in target international normalized ratio +0.19, 95% CI 0.06 to 0.33) and insulin (SMD for percentage of time in target glucose range: +1.27, 95% CI 0.56 to 1.98);3. it decreased the time to achieve stabilization for oral anticoagulants (SMD -0.56, 95% CI -1.07 to -0.04);4. it decreased the thromboembolism events (rate ratio 0.68, 95% CI 0.49 to 0.94) and tended to decrease bleeding events for anticoagulants although the difference was not significant (rate ratio 0.81, 95% CI 0.60 to 1.08). It tended to decrease unwanted effects for aminoglycoside antibiotics (nephrotoxicity: RR 0.67, 95% CI 0.42 to 1.06) and anti-rejection drugs (cytomegalovirus infections: RR 0.90, 95% CI 0.58 to 1.40);5. it tended to reduce the length of time spent in the hospital although the difference was not significant (SMD -0.15, 95% CI -0.33 to 0.02) and to achieve comparable or better cost-effectiveness ratios than usual care;6. there was no evidence of differences in mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants.For all outcomes, statistical heterogeneity quantified by I(2) statistics was moderate to high. AUTHORS' CONCLUSIONS This review update suggests that computerized advice for drug dosage has some benefits: it increases the serum concentrations for aminoglycoside antibiotics and improves the proportion of people for which the plasma drug is within the therapeutic range for aminoglycoside antibiotics.It leads to a physiological parameter more often within the desired range for oral anticoagulants and insulin. It decreases the time to achieve stabilization for oral anticoagulants. It tends to decrease unwanted effects for aminoglycoside antibiotics and anti-rejection drugs, and it significantly decreases thromboembolism events for anticoagulants. It tends to reduce the length of hospital stay compared with routine care while comparable or better cost-effectiveness ratios were achieved.However, there was no evidence that decision support had an effect on mortality or other clinical adverse events for insulin (hypoglycaemia), anaesthetic agents, anti-rejection drugs and antidepressants. In addition, there was no evidence to suggest that some decision support technical features (such as its integration into a computer physician order entry system) or aspects of organization of care (such as the setting) could optimize the effect of computerized advice.Taking into account the high risk of bias of, and high heterogeneity between, studies, these results must be interpreted with caution.
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Affiliation(s)
- Florence Gillaizeau
- French Cochrane Center, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, France, 75004
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del Mar Fernández de Gatta M, Martin-Suarez A, Lanao JM. Approaches for dosage individualisation in critically ill patients. Expert Opin Drug Metab Toxicol 2013; 9:1481-93. [PMID: 23898816 DOI: 10.1517/17425255.2013.822486] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Pharmacokinetic variability in critically ill patients is the result of the overlapping of multiple pathophysiological and clinical factors. Unpredictable exposure from standard dosage regimens may influence the outcome of treatment. Therefore, strategies for dosage individualisation are recommended in this setting. AREAS COVERED The authors focus on several approaches for dosage individualisation that have been developed, ranging from the well-established therapeutic drug monitoring (TDM) up to the innovative application of pharmacogenomics criteria. Furthermore, the authors summarise the specific population pharmacokinetic models for different drugs developed for critically ill patients to improve the initial dosage selection and the Bayesian forecasting of serum concentrations. The authors also consider the use of Monte Carlo simulation for the selection of dosage strategies. EXPERT OPINION Pharmacokinetic/pharmacodynamics (PK/PD) modelling and dosage individualisation methods based on mathematical and statistical criteria will contribute in improving pharmacologic treatment in critically ill patients. Moreover, substantial effort will be necessary to integrate pharmacogenomics criteria into critical care practice. The lack of availability of target biomarkers for dosage adjustment emphasizes the value of TDM which allows a large part of treatment outcome variability to be controlled.
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Affiliation(s)
- M del Mar Fernández de Gatta
- University of Salamanca, Institute of Biomedical Research of Salamanca (IBSAL), Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy , Avda. Licenciado Méndez Núñez, 37007 Salamanca , Spain +0034 923 294 536 ; +0034 923 294 515 ;
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Neely M, Jelliffe R. Practical, Individualized Dosing: 21st Century Therapeutics and the Clinical Pharmacometrician. J Clin Pharmacol 2013; 50:842-7. [DOI: 10.1177/0091270009356572] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Goncalves-Pereira J, Paiva JA. Dose modulation: a new concept of antibiotic therapy in the critically ill patient? J Crit Care 2013; 28:341-6. [PMID: 23337485 DOI: 10.1016/j.jcrc.2012.11.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 11/26/2012] [Accepted: 11/30/2012] [Indexed: 01/29/2023]
Abstract
Considerable evidence has shown that adequate antibiotic therapy is of utmost importance in the critically ill septic patient. However, antibiotic concentration may be insufficient early in infection course. We propose the concept of dose modulation, meaning front-line variability of antibiotic dose, according to patient and microorganism characteristics, followed by its reduction after clinical response and patient recovery. Therefore, dose modulation means concentrating the largest weight of antibiotics at the front-end, when the microbial load is higher and the pharmacokinetic changes poses the highest risk of underdosing and nibbling off antibiotic dose, when the sepsis syndrome is improving, guided by pharmacokinetic and pharmacodynamic data.
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Affiliation(s)
- Joao Goncalves-Pereira
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, CHLO, Estrada do Forte do Alto do Duque, 1449-005 Lisboa, Portugal.
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Zegbeh H, Bleyzac N, Berhoune C, Bertrand Y. Vancomycine : quelles doses pour une meilleure efficacité en hémato-oncologie pédiatrique ? Arch Pediatr 2011; 18:850-5. [DOI: 10.1016/j.arcped.2011.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 04/13/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
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Computer-assisted cyclosporine dosing performs better than traditional dosing in renal transplant recipients: results of a pilot study. Ther Drug Monit 2010; 32:152-8. [PMID: 20216113 DOI: 10.1097/ftd.0b013e3181d3f822] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cyclosporine A (CsA) is widely used after organ transplantation. Its narrow therapeutic window and large pharmacokinetic variability makes therapeutic drug monitoring (TDM) demanding and frequent dose adjustments are needed, especially early after transplantation. The aim of the present pilot study was to compare accuracy of CsA TDM by experienced clinicians against a computer-assisted dosing model. Renal transplant recipients on CsA, prednisolone, and mycophenolate were included 2 weeks after transplantation, randomized (1:1) to either computer dosing (MAP-BE) or control (CONTR) and followed for at least 8 weeks. A maximum a posteriori probability Bayesian estimation method, applying a population pharmacokinetic model and the POSTHOC option in nonlinear mixed effects modeling, was used to individualize CsA doses in the MAP-BE group. Forty patients (31 men, 27.5% living donor) between 28 and 80 years were included. A total of 798 CsA concentration measurements and adherent dosing evaluations/adjustments were performed. During the entire study, blood concentrations were on average 10% +/- 5% from the predefined therapeutic target range in the MAP-BE group, as compared with 13% +/- 8% in the CONTR group (P = 0.042). However, there was no significant difference between groups regarding the percentage of CsA concentrations truly within the therapeutic windows [MAP-BE: 37% +/- 17%, CONTR: 33% +/- 15% (P = 0.57)] or in CsA dose [MAP-BE: 3.55 +/- 0.8, CONTR: 3.90 +/- 0.9 mg/kg/d (P = 0.26)]. Acute rejections were present in 4 and 3 patients, respectively (P = 1.00). The computer-assisted TDM-targeted CsA blood concentrations significantly better than experienced transplant physicians. A possible favorable effect on short- and long-term outcome needs to be verified in further, properly powered, clinical trials.
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Hiraki Y, Onga T, Mizoguchi A, Tsuji Y. ORIGINAL ARTICLE: Investigation of the prediction accuracy of vancomycin concentrations determined by patient-specific parameters as estimated by Bayesian analysis. J Clin Pharm Ther 2010; 35:527-32. [DOI: 10.1111/j.1365-2710.2009.01126.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fernández de Gatta MDM, Santos Buelga D, Sánchez Navarro A, Dominguez-Gil A, García MJ. Vancomycin dosage optimization in patients with malignant haematological disease by pharmacokinetic/pharmacodynamic analysis. Clin Pharmacokinet 2009; 48:273-80. [PMID: 19492872 DOI: 10.2165/00003088-200948040-00005] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The use of vancomycin against Staphylococcus aureus is currently debated because of the increasing resistance developed by this pathogen. Nevertheless, antibacterial effectiveness is a limited resource that must be protected and restored. Novel dosage strategies based on pharmacokinetic/pharmacodynamic analyses are needed to retain effectiveness that could improve drug exposure in patients infected with such pathogens. OBJECTIVE The aim of this study was to assess whether standard or higher vancomycin dosages are required to increase the probability of attaining a target pharmacokinetic/pharmacodynamic index for several staphylococcal strains and thus to estimate the minimum vancomycin daily dose related to a high probability of effective treatment in patients with malignant haematological disease. METHODS Monte Carlo simulation was performed to calculate the cumulative fraction of response (CFR) for different vancomycin daily dosages, using a population pharmacokinetic model previously defined in patients with malignant haematological disease and the minimum inhibitory concentration (MIC) distribution for vancomycin against several staphylococcal species (vancomycin-susceptible S. aureus and vancomycin-intermediate S. aureus [VISA], S. epidermidis, S. haemolyticus and coagulase-negative Staphylococcus [CNS] species) obtained from the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in order to predict the dose that would achieve the pharmacokinetic/pharmacodynamic index value associated with efficacy (the area under the concentration-time curve from 0 to 24 hours divided by the MIC [AUC(24)/MIC >/=400]). RESULTS CFR values showed dependence on the renal function of the patient and the causative pathogen. Only in patients with a creatinine clearance (CL(CR)) <60 mL/min did the standard vancomycin dosage (2000 mg/day) induce CFRs >60% for all staphylococci, except the VISA strains. CFRs for S. aureus of 90.6%, 47.3% and 31.2% for CL(CR) values of <60, 60-120 and >120 mL/min, respectively, were obtained, whereas for the VISA strains, the corresponding values were only 14.0%, 0.3% and 0%. The impact of potential pathogens on CFRs is also significant. According to our pharmacokinetic/pharmacodynamic analysis, in patients with normal renal function (CL(CR) between 60 and 120 mL/min) vancomycin 2000 mg/day leads to a risk of not achieving the recommended AUC(24)/MIC breakpoint of 52.7%, 70.4%, 74.9% and 80.3% for S. aureus, S. haemolyticus, CNS and S. epidermidis, respectively. Application of our results to clinical practice graphically allows us to obtain the recommended dose for any a priori-selected probability of attaining the AUC(24)/MIC ratio of >/=400 and to evaluate the CFRs for any dosing regimen used in this population group, depending on the patients' renal function. CONCLUSIONS Application of pharmacokinetic/pharmacodynamic analysis based on Monte Carlo simulation offers an excellent tool for selecting the therapeutic option with the highest probability of clinical success in patients with malignant haematological disease. Thus, for vancomycin-susceptible S. aureus, if a CFR >/=80 is assumed as clinically acceptable, vancomycin doses of 1500, 3000 and 4000 mg/day for a CL(CR) of <60, 60-120 and >120 mL/min, respectively, will be required.
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Pea F, Viale P. Bench-to-bedside review: Appropriate antibiotic therapy in severe sepsis and septic shock--does the dose matter? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:214. [PMID: 19519961 PMCID: PMC2717408 DOI: 10.1186/cc7774] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Appropriate antibiotic therapy in patients with severe sepsis and septic shock should mean prompt achievement and maintenance of optimal exposure at the infection site with broad-spectrum antimicrobial agents administered in a timely manner. Once the causative pathogens have been identified and tested for in vitro susceptibility, subsequent de-escalation of antimicrobial therapy should be applied whenever feasible. The goal of appropriate antibiotic therapy must be pursued resolutely and with continuity, in view of the ongoing explosion of antibiotic-resistant infections that plague the intensive care unit setting and of the continued decrease in new antibiotics emerging. This article provides some principles for the correct handling of antimicrobial dosing regimens in patients with severe sepsis and septic shock, in whom various pathophysiological conditions may significantly alter the pharmacokinetic behaviour of drugs.
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Affiliation(s)
- Federico Pea
- Department of Experimental and Clinical Pathology, Institute of Clinical Pharmacology & Toxicology, Medical School, University of Udine, 33100 Udine, Italy.
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Prospectively validated dosing nomograms for maximizing the pharmacodynamics of vancomycin administered by continuous infusion in critically ill patients. Antimicrob Agents Chemother 2009; 53:1863-7. [PMID: 19223642 DOI: 10.1128/aac.01149-08] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The efficacy of vancomycin against methicillin-resistant Staphylococcus aureus (MRSA)-related infections has been called into question by recent findings of higher rates of failure of vancomycin treatment of infections caused by strains with high MICs. Continuous infusion may be the best way to maximize the time-dependent activity of vancomycin. The aim of this study was to create dosing nomograms in relation to different creatinine clearance (CL(Cr)) estimates for use in daily clinical practice to target the steady-state concentrations (C(ss)s) of vancomycin during continuous infusion at 15 to 20 mg/liter (after the administration of an initial loading dose of 15 mg/kg of body weight over 2 h). The correlation between vancomycin clearance (CL(v)) and CL(Cr) was retrospectively assessed in a cohort of critically ill patients (group 1, n = 70) to create a formula for dosage calculation to target C(ss) at 15 mg/liter. The performance of this formula was prospectively validated in a similar cohort (group 2, n = 63) by comparison of the observed and the predicted C(ss)s. A significant relationship between CL(v) and CL(Cr) was observed in group 1 (P < 0.001). The application of the calculated formula to vancomycin dosing in group 2 {infusion rate (g/24 h) = [0.029 x CL(Cr) (ml/min) + 0.94] x target C(ss) x (24/1,000)} led to a significant correlation between the observed and the predicted C(ss)s (r = 0.80, P < 0.001). Two dosing nomograms based on CL(Cr) were created to target the vancomycin C(ss) at 15 and 20 mg/liter in critically ill patients. These nomograms could be helpful in improving the vancomycin treatment of MRSA infections, especially in the presence of borderline-susceptible pathogens and/or of pathophysiological conditions which may enhance the clearance of vancomycin, while potentially avoiding the increased risk of nephrotoxicity observed with the use of high intermittent doses of vancomycin.
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Scaglione F, Paraboni L. Pharmacokinetics/pharmacodynamics of antibacterials in the Intensive Care Unit: setting appropriate dosing regimens. Int J Antimicrob Agents 2008; 32:294-301. [PMID: 18621508 DOI: 10.1016/j.ijantimicag.2008.03.015] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Accepted: 03/26/2008] [Indexed: 12/18/2022]
Abstract
Patients admitted to Intensive Care Units (ICUs) are at very high risk of developing severe nosocomial infections. Consequently, antimicrobials are among the most important and commonly prescribed drugs in the management of these patients. Critically ill patients in ICUs include representatives of all age groups with a range of organ dysfunction related to severe acute illness that may complicate long-term illness. The range of organ dysfunction, together with drug interactions and other therapeutic interventions (e.g. haemodynamically active drugs and continuous renal replacement therapies), may strongly impact on antimicrobial pharmacokinetics in critically ill patients. In the last decade, it has become apparent that the intrinsic pharmacokinetic (PK) and pharmacodynamic (PD) properties are the major determinants of in vivo efficacy of antimicrobial agents. PK/PD parameters are essential in facilitating the translation of microbiological activity into clinical situations, ensuring a successful outcome. In this review, we analyse the typical patterns of antimicrobial activity and the corresponding PK/PD parameters, with a special focus on a PK/PD dosing approach of the antimicrobial agent classes commonly utilised in the ICU setting.
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Affiliation(s)
- Francesco Scaglione
- Department of Pharmacology, Chemotherapy and Toxicology, Faculty of Medicine, University of Milan, Milan, Italy.
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Lee P, DiPersio D, Jerome RN, Wheeler AP. Approaching and analyzing a large literature on vancomycin monitoring and pharmacokinetics. J Med Libr Assoc 2007; 95:374-80. [PMID: 17971884 DOI: 10.3163/1536-5050.95.4.374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Patricia Lee
- Eskind Biomedical Library, Vanderbilt University Medical Center, Nashville, TN, USA.
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Hu PJH, Cheng TH, Wei CP, Yu CH, Chan ALF, Wang HY. Managing Clinical Use of High-Alert Drugs: A Supervised Learning Approach to Pharmacokinetic Data Analysis. ACTA ACUST UNITED AC 2007. [DOI: 10.1109/tsmca.2007.897700] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Okamoto G, Sakamoto T, Kimura M, Ukishima Y, Sonoda A, Mori N, Kato Y, Maeda T, Kagawa Y. Serum cystatin C as a better marker of vancomycin clearance than serum creatinine in elderly patients. Clin Biochem 2007; 40:485-90. [PMID: 17336280 DOI: 10.1016/j.clinbiochem.2007.01.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2006] [Revised: 01/09/2007] [Accepted: 01/15/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study is to assess the usefulness of the concentration of cystatin C (Cys-C) in serum for predicting the clearance of vancomycin (CLvcm) compared with the serum concentration of creatinine (SCr) in the elderly. METHODS Thirty-nine serum samples were obtained from 24 elderly patients (65 years and older). Creatinine clearance (CLcr) and the glomerular filtration rate calculated from the concentration of Cys-C (GFRcys-c) were estimated using Cockcroft & Gault's formula and Larsson's formula, respectively. RESULTS The correlation constant for CLvcm and the reciprocal of Cys-C (p=0.883) was significantly higher than that for CLvcm and the reciprocal of SCr (p=0.575, p<0.005). GFRcys-c was strongly correlated with CLvcm (p=0.883) and the constant was significantly higher than that for the correlation between CLvcm and CLcr (p=0.684, p<0.05). These results suggest that the serum concentration of Cys-C is a more reliable marker for predicting CLvcm than is SCr in elderly patients.
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Affiliation(s)
- Go Okamoto
- Department of Clinical Pharmaceutics and Pharmacy Practice, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka 422-8526, Japan
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Murphy JE, Gillespie DE, Bateman CV. Predictability of vancomycin trough concentrations using seven approaches for estimating pharmacokinetic parameters. Am J Health Syst Pharm 2006; 63:2365-70. [PMID: 17106010 DOI: 10.2146/ajhp060047] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Seven methods for estimating vancomycin pharmacokinetic parameters were studied to determine which method best predicted measured concentrations for patients at a community teaching hospital. METHODS Data from adult patients who were given vancomycin and had at least one steady-state trough concentration measured were retrospectively reviewed. Data analyzed included laboratory test values, concomitant medications, weight, height, sex, age, laboratory cultures, medical procedures performed, vancomycin dose and interval, measured vancomycin concentrations, and time of measurement. Relevant data were used in seven predictor methods that estimate volume of distribution, vancomycin clearance, and elimination rate constant to determine which yielded the best predictions of actual measured concentrations in the patient population. RESULTS Data from 189 patients were included in the analyses. The coefficients of determination for the methods ranged from 0.114 to 0.234. Bias ranged from -5.90 to 0.69 mg/L, and precision ranged from 6.05 to 8.08. The Matzke method had the best combination of the least bias and best precision. Predictions were within 2.5 and 5 mg/L of measured concentrations 18.0-43.9% and 43.4-66.1% of the time, respectively. The percentage of predictions within 25% and 50% of measured concentrations ranged from 7.9% to 31.2% and from 18.0% to 48.1%, respectively. Ten (5.3%) patients had trough concentrations exceeding 20 mg/L, and 11 (5.8%) had trough concentrations of < or = 3 mg/L. CONCLUSION The seven methods studied for estimating vancomycin pharmacokinetic parameters varied widely in predicting vancomycin trough concentrations compared with measured serum concentrations and were not sufficiently reliable to replace therapeutic monitoring of vancomycin serum concentrations.
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Affiliation(s)
- John E Murphy
- College of Pharmacy, The University of Arizona, Tucson, AZ 85721-0207, USA.
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Pea F, Viale P, Furlanut M. Antimicrobial therapy in critically ill patients: a review of pathophysiological conditions responsible for altered disposition and pharmacokinetic variability. Clin Pharmacokinet 2006; 44:1009-34. [PMID: 16176116 DOI: 10.2165/00003088-200544100-00002] [Citation(s) in RCA: 228] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Antimicrobials are among the most important and commonly prescribed drugs in the management of critically ill patients. Selecting the appropriate antimicrobial at the commencement of therapy, both in terms of spectrum of activity and dose and frequency of administration according to concentration or time dependency, is mandatory in this setting. Despite appropriate standard dosage regimens, failure of the antimicrobial treatment may occur because of the inability of the antimicrobial to achieve adequate concentrations at the infection site through alterations in its pharmacokinetics due to underlying pathophysiological conditions. According to the intrinsic chemicophysical properties of antimicrobials, hydrophilic antimicrobials (beta-lactams, aminoglycosides, glycopeptides) have to be considered at much higher risk of inter- and intraindividual pharmacokinetic variations than lipophilic antimicrobials (macrolides, fluoroquinolones, tetracyclines, chloramphenicol, rifampicin [rifampin]) in critically ill patients, with significant frequent fluctuations of plasma concentrations that may require significant dosage adjustments. For example, underexposure may occur because of increased volume of distribution (as a result of oedema in sepsis and trauma, pleural effusion, ascites, mediastinitis, fluid therapy or indwelling post-surgical drainage) and/or enhanced renal clearance (as a result of burns, drug abuse, hyperdynamic conditions during sepsis, acute leukaemia or use of haemodynamically active drugs). On the other hand, overexposure may occur because of a drop in renal clearance caused by renal impairment. Care with all these factors whenever choosing an antimicrobial may substantially improve the outcome of antimicrobial therapy in critically ill patients. However, since these situations may often coexist in the same patient and pharmacokinetic variability may be unpredictable, the antimicrobial policy may further benefit from real-time application of therapeutic drug monitoring, since this practice, by tailoring exposure to the individual patient, may consequently be helpful both in improving the outcome of antimicrobial therapy and in containing the spread of resistance in the hospital setting.
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Affiliation(s)
- Federico Pea
- Department of Experimental and Clinical Pathology and Medicine, Medical School, Institute of Clinical Pharmacology and Toxicology, University of Udine, Udine, Italy
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