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Verrest L, Roseboom IC, Wasunna M, Mbui J, Njenga S, Musa AM, Olobo J, Mohammed R, Ritmeijer K, Chu WY, Huitema ADR, Solomos A, Alves F, Dorlo TPC. Population pharmacokinetics of a combination of miltefosine and paromomycin in Eastern African children and adults with visceral leishmaniasis. J Antimicrob Chemother 2023; 78:2702-2714. [PMID: 37726401 PMCID: PMC10631828 DOI: 10.1093/jac/dkad286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES To improve visceral leishmaniasis (VL) treatment in Eastern Africa, 14- and 28-day combination regimens of paromomycin plus allometrically dosed miltefosine were evaluated. As the majority of patients affected by VL are children, adequate paediatric exposure to miltefosine and paromomycin is key to ensuring good treatment response. METHODS Pharmacokinetic data were collected in a multicentre randomized controlled trial in VL patients from Kenya, Sudan, Ethiopia and Uganda. Patients received paromomycin (20 mg/kg/day for 14 days) plus miltefosine (allometric dose for 14 or 28 days). Population pharmacokinetic models were developed. Adequacy of exposure and target attainment of paromomycin and miltefosine were evaluated in children and adults. RESULTS Data from 265 patients (59% ≤12 years) were available for this pharmacokinetic analysis. Paromomycin exposure was lower in paediatric patients compared with adults [median (IQR) end-of-treatment AUC0-24h 187 (162-203) and 242 (217-328) µg·h/mL, respectively], but were both within the IQR of end-of-treatment exposure in Kenyan and Sudanese adult patients from a previous study. Cumulative miltefosine end-of-treatment exposure in paediatric patients and adults [AUCD0-28 517 (464-552) and 524 (456-567) µg·day/mL, respectively] and target attainment [time above the in vitro susceptibility value EC90 27 (25-28) and 30 (28-32) days, respectively] were comparable to previously observed values in adults. CONCLUSIONS Paromomycin and miltefosine exposure in this new combination regimen corresponded to the desirable levels of exposure, supporting the implementation of the shortened 14 day combination regimen. Moreover, the lack of a clear exposure-response and exposure-toxicity relationship indicated adequate exposure within the therapeutic range in the studied population, including paediatric patients.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ignace C Roseboom
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Simon Njenga
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Joseph Olobo
- Department of Immunology and Molecular Biology, Makerere University, Kampala, Uganda
| | - Rezika Mohammed
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | | | - Wan-Yu Chu
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Fabiana Alves
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Wang F, Zhou M, Wang W, Zhu Z, Yan Y. Age-associated augmented renal clearance and low BMI trigger suboptimal vancomycin trough concentrations in children with haematologic diseases: data of 1453 paediatric patients from 2017 to 2022. BMC Pediatr 2023; 23:528. [PMID: 37880633 PMCID: PMC10601245 DOI: 10.1186/s12887-023-04288-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/05/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND It is usually difficult for the trough concentration of vancomycin to reach the recommended lower limit of 10 mg/L per the label dose in the paediatric population. Moreover, children with haematologic diseases who suffer from neutropenia are more likely to have lower exposure of vancomycin, and the risk factors have been poorly explored. METHOD We reviewed and analysed the initial trough concentration of vancomycin and synchronous cytometry and biochemical parameters in the blood of 1453 paediatric patients with haematologic diseases over a 6 year period, from 2017 to 2022. RESULTS Forty-five percent of the enrolled children had vancomycin trough concentrations below 5 mg/L after receiving a dose of 40 mg/kg/day, and the multiple regression showed that age (OR = 0.881, 95% CI 0.855 to 0.909, P < 0.001), BMI (OR = 0.941, 95% CI 0.904 to 0.980, P = 0.003) and the glomerular filtration rate (OR = 1.006, 95% CI 1.004 to 1.008, P < 0.001) were independent risk factors. A total of 79.7% of the children experienced augmented renal clearance, which was closely correlated to age-associated levels of serum creatinine. The vancomycin trough concentration was higher in children with aplastic anaemia than in those with other haematologic diseases due to a higher BMI and a lower glomerular filtration rate. CONCLUSION Age-associated augmented renal clearance and low BMI values contributed to suboptimal trough concentrations of vancomycin in children with haematologic diseases, and the effects of long-term use of cyclosporine and glucocorticoids need to be taken into account.
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Affiliation(s)
- Fengjiao Wang
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China
| | - Mi Zhou
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China
| | - Wenjuan Wang
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China
| | - Zengyan Zhu
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China.
| | - Yinghui Yan
- Department of Pharmacy, Children's Hospital of Soochow University, 92# Street Zhongnan, Suzhou, 215025, Jiangsu, China.
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Contejean A, Maillard A, Canouï E, Kernéis S, Fantin B, Bouscary D, Parize P, Garcia-Vidal C, Charlier C. Advances in antibacterial treatment of adults with high-risk febrile neutropenia. J Antimicrob Chemother 2023; 78:2109-2120. [PMID: 37259598 DOI: 10.1093/jac/dkad166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND High-risk febrile neutropenia (HR-FN) is a life-threatening complication in patients with haematological malignancies or receiving myelosuppressive chemotherapy. Since the last international guidelines were published over 10 years ago, there have been major advances in the understanding and management of HR-FN, including on antibiotic pharmacokinetics and discontinuation/de-escalation strategies. OBJECTIVES Summarizing major advances in the field of antibacterial therapy in patients with HR-FN: empirical therapy, pharmacokinetics of antibiotics and antibiotic stewardship. SOURCES Narrative review based on literature review from PubMed. We focused on studies published between 2010 and 2023 about the pharmacokinetics of antimicrobials, management of antimicrobial administration, and discontinuation/de-escalation strategies. We did not address antimicrobial prophylaxis, viral or fungal infections. CONTENT Several high-quality publications have highlighted important modifications of antibiotic pharmacokinetics in HR-FN, with standard dosages exposing patients to underdosing. These recent clinical and population pharmacokinetics studies help improve management protocols with optimized initial dosing and infusion rules for β-lactams, vancomycin, daptomycin and amikacin; they highlight the potential benefits of therapeutic drug monitoring. A growing body of evidence also shows that antibiotic discontinuation/de-escalation strategies are beneficial for bacterial ecology and patients' outcome. We further discuss methods and limitations for implementation of such protocols in haematology. IMPLICATIONS We highlight recent information about the management of antibacterial therapy in HR-FN that might be considered in updated guidelines for HR-FN management.
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Affiliation(s)
- Adrien Contejean
- Service d'Hématologie, Centre Hospitalier Annecy Genevois, 1 Avenue de l'hôpital, F-74370 Epagny Metz-Tessy, France
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
| | - Alexis Maillard
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Etienne Canouï
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Solen Kernéis
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Équipe de Prévention du Risque Infectieux, AP-HP, Hôpital Bichat, F-75018 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
| | - Bruno Fantin
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Département de Médecine Interne, AP-HP, Hôpital Beaujon, F-92110, Clichy, France
| | - Didier Bouscary
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Service d'Hématologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Perrine Parize
- Service de Maladies Infectieuses, AP-HP, APHP.CUP, Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- CIBERINF, Madrid, Spain
| | - Caroline Charlier
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- National Reference Center Listeriosis WHO Collaborating Center, Institut Pasteur, F-75015 Paris, France
- Biology of Infection Unit, Inserm U1117 Institut Pasteur, F-75015 Paris, France
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Gatti M, Pea F. The expert clinical pharmacological advice program for tailoring on real-time antimicrobial therapies with emerging TDM candidates in special populations: how the ugly duckling turned into a swan. Expert Rev Clin Pharmacol 2023; 16:1035-1051. [PMID: 37874608 DOI: 10.1080/17512433.2023.2274984] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION The growing spread of infections caused by multidrug-resistant pathogens makes the need of tailoring antimicrobial therapies by means of a 'patient-centered' approach fundamental. In this scenario, therapeutic drug monitoring (TDM) of emerging antimicrobial candidates may be a valuable approach, but expert interpretation of TDM results should be granted for making them more clinically useful. The MD Clinical Pharmacologist may take over this task since this specialist may couple PK/PD expertise on drugs with a medical background and may provide expert interpretation of TDM results of antimicrobials for tailoring therapy on real-time in each single patient based on specific both drug/pathogen issues and patient issues. AREAS COVERED This article aims to highlight the main key-points and organizational aspects for implementing a successful TDM-based expert clinical pharmacological advice (ECPA) program for tailoring antimicrobial therapies on real-time in different hospitalized patient special populations. EXPERT OPINION TDM-based ECPA programs lead by the MD Clinical Pharmacologist may represent a way forward for maximizing clinical efficacy and for minimizing the risk of resistance developments and/or toxicity of antimicrobials. Stakeholders should be aware of the fact that this innovative approach may be cost-effective.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Clinical Pharmacology Unit, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
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Ishikawa K, Shibutani K, Kawai F, Ota E, Takahashi O, Mori N. Effectiveness of Extended or Continuous vs. Bolus Infusion of Broad-Spectrum Beta-Lactam Antibiotics for Febrile Neutropenia: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2023; 12:1024. [PMID: 37370343 DOI: 10.3390/antibiotics12061024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
This systematic review aimed to compare extended infusion or continuous infusion with bolus infusion for febrile neutropenia (FN). We included clinical trials comparing extended or continuous infusion with bolus infusion of beta-lactam antibiotics as empirical treatment for FN and evaluated the clinical failure, all-cause mortality, and adverse event rates. Five articles (three randomized controlled trials (RCTs) and two retrospective studies) from 2014 to 2022 were included. Clinical failure was assessed with a risk ratio (RR) (95% coincident interval (CI)) of 0.74 (0.53, 1.05) and odds ratio (OR) (95% CI) of 0.14 (0.02, 1.17) in the 2 RCTs and retrospective studies, respectively. All-cause mortality was assessed with an RR (95% CI) of 1.25 (0.44, 3.54) and OR (95% CI) of 1.00 (0.44, 2.23) in the RCTs and retrospective studies, respectively. Only 1 RCT evaluated adverse events (with an RR (95% CI) of 0.46 (0.13, 1.65)). The quality of evidence was "low" for clinical failure and all-cause mortality in the RCTs. In the retrospective studies, the clinical failure and all-cause mortality evidence qualities were considered "very low" due to the study design. Extended or continuous infusion of beta-lactam antibiotics did not reduce mortality better than bolus infusion but was associated with shorter fever durations and fewer adverse events.
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Affiliation(s)
- Kazuhiro Ishikawa
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo 104-8560, Japan
| | - Koko Shibutani
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo 104-8560, Japan
| | - Fujimi Kawai
- Library, Center for Academic Resources, St. Luke's International University, Tokyo 104-0044, Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Sciences, St. Luke's International University, Tokyo 104-0044, Japan
- Tokyo Foundation for Policy Research, Tokyo 106-0032, Japan
| | - Osamu Takahashi
- Graduate School of Public Health, St. Luke's International University, Tokyo 104-0045, Japan
| | - Nobuyoshi Mori
- Department of Infectious Diseases, St. Luke's International Hospital, Tokyo 104-8560, Japan
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Alzahrani AM, Naeem A, AlAzmi A, Hakami AY, Karim S, Ali AS, Kamel FO, Alzhrani RM, Alkhaldi TS, Maghrabi LA, Alshehri NF, Alzahrani YA. Altered Pharmacokinetics Parameters of Vancomycin in Patients with Hematological Malignancy with Febrile Neutropenia, a Bayesian Software Estimation. Antibiotics (Basel) 2023; 12:979. [PMID: 37370298 DOI: 10.3390/antibiotics12060979] [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: 03/30/2023] [Revised: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023] Open
Abstract
The pharmacokinetics of vancomycin vary significantly between specific groups of patients, such as critically ill patients and patients with hematological malignancy (HM) with febrile neutropenia (FN). Recent evidence suggests that the use of the usual standard dose of antibiotics in patients with FN may not offer adequate exposure due to pharmacokinetic variability (PK). Therefore, the purpose of this study is to assess the effect of FN on AUC0-24 as a key parameter for vancomycin monitoring, as well as to determine which vancomycin PK parameters are affected by the presence of FN using Bayesian software PrecisePK in HM with FN. This study was carried out in King Abdulaziz Medical City. All adult patients who were admitted to the Princess Norah Oncology Center PNOC between 1 January and 2017 and 31 December 2020, hospitalized and received vancomycin with a steady-state trough concentration measured before the fourth dose, were included. During the trial period, 297 patients received vancomycin during their stay at the oncology center, 217 of them meeting the inclusion criteria. Pharmacokinetic parameters were estimated for the neutropenic and non-FN patients using the precise PK Bayesian platform. The result showed that there was a significant difference (p < 0.05) in vancomycin clearance Clvan, the volume of distribution at a steady-state Vdss, the volume of distribution for peripheral compartment Vdp, half-life for the elimination phase t½β, and the first-order rate constant for the elimination process β in FN compared to non-FN patients. Furthermore, AUC0-24 was lower for FN patients compared to non-FN patients, p < 0.05. FN has a significant effect on the PK parameters of vancomycin and AUC0-24, which may require specific consideration during the treatment initiation.
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Affiliation(s)
- Abdullah M Alzahrani
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Anjum Naeem
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Aeshah AlAzmi
- Pharmaceutical Care Department, Ministry of National Guard-Health Affairs, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Alqassem Y Hakami
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Shahid Karim
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ahmed S Ali
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Fatemah Omer Kamel
- Department of Pharmacology, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Rami M Alzhrani
- Department of Pharmaceutics and Industrial Pharmacy, College of Pharmacy, Taif University, Taif 21944, Saudi Arabia
| | - Teaf S Alkhaldi
- College of Pharmacy, Taif University, Taif 21944, Saudi Arabia
| | | | - Norah F Alshehri
- Department of Pharmacy, East Jeddah Hospital, Ministry of Health, Jeddah 22253, Saudi Arabia
| | - Yahya A Alzahrani
- King Abdullah International Medical Research Center, Jeddah 21423, Saudi Arabia
- Department of Pharmacy, East Jeddah Hospital, Ministry of Health, Jeddah 22253, Saudi Arabia
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Belabbas T, Yamada T, Egashira N, Hirota T, Suetsugu K, Mori Y, Kato K, Akashi K, Ieiri I. Population pharmacokinetic model and dosing optimization of vancomycin in hematologic malignancies with neutropenia and augmented renal clearance. J Infect Chemother 2023; 29:391-400. [PMID: 36682608 DOI: 10.1016/j.jiac.2023.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
AIM Data on the pharmacokinetics (PK) and area under the curve (AUC)-based dosing strategy of vancomycin (VCM) in hematologic malignancies are limited. According to our preliminary narrative review, only a few population PK analyses in hematologic malignancies have been performed. Therefore, we aimed to develop a population PK model, investigate the factors influencing VCM PK, and propose an optimal dosing regimen for hematologic malignancies. METHODS A retrospective study was conducted in patients with underlying hematologic malignancies treated with VCM. A total of 148 patients were enrolled for population PK modeling. Simulation analyses were performed to identify dosing regimens achieving a target exposure of AUC0-24 of 400-600 mg h/L at the steady-state. RESULTS The VCM PK data were best described with a one-compartment model. Significant covariates included creatinine clearance (Ccr), diagnosis of acute myeloid leukemia (AML) and neutropenia on VCM clearance (CL), and body weight (WT) on the volume of distribution (Vd). The typical values of CL and Vd were 3.09 L/h (normalized to Ccr value of 90 mL/min) and 122 L/70 kg, respectively. Concerning the effect on VCM dosing, AML patients required 15% higher doses than non-AML patients, independently of renal function. In contrast, for neutropenic patients, only those with augmented renal clearance (ARC, Ccr value ≥ 130 mL/min) required a 10% dose increase compared to non-neutropenic patients. CONCLUSION AML patients with neutropenia and ARC represent a critical population with a higher risk of VCM underexposure. Thus, individualized dosing adjustment and therapeutic drug monitoring are strongly recommended.
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Affiliation(s)
- Tassadit Belabbas
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takaaki Yamada
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nobuaki Egashira
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan; Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takeshi Hirota
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kimitaka Suetsugu
- Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuo Mori
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Kato
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ichiro Ieiri
- Department of Clinical Pharmacology and Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan; Department of Pharmacy, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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8
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Zhou DH, Zhang QG. Fast drug rotation reduces bacterial resistance evolution in a microcosm experiment. J Evol Biol 2023; 36:641-649. [PMID: 36808770 DOI: 10.1111/jeb.14163] [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: 09/18/2022] [Revised: 11/17/2022] [Accepted: 01/16/2023] [Indexed: 02/21/2023]
Abstract
Drug rotation (cycling), in which multiple drugs are administrated alternatively, has the potential for limiting resistance evolution in pathogens. The frequency of drug alternation could be a major factor to determine the effectiveness of drug rotation. Drug rotation practices often have low frequency of drug alternation, with an expectation of resistance reversion. Here we, based on evolutionary rescue and compensatory evolution theories, suggest that fast drug rotation can limit resistance evolution in the first place. This is because fast drug rotation would give little time for the evolutionarily rescued populations to recover in population size and genetic diversity, and thus decrease the chance of future evolutionary rescue under alternate environmental stresses. We experimentally tested this hypothesis using the bacterium Pseudomonas fluorescens and two antibiotics (chloramphenicol and rifampin). Increasing drug rotation frequency reduced the chance of evolutionary rescue, and most of the finally surviving bacterial populations were resistant to both drugs. Drug resistance incurred significant fitness costs, which did not differ among the drug treatment histories. A link between population sizes during the early stages of drug treatment and the end-point fates of populations (extinction vs survival) suggested that population size recovery and compensatory evolution before drug shift increase the chance of population survival. Our results therefore advocate fast drug rotation as a promising approach to reduce bacterial resistance evolution, which in particular could be a substitute for drug combination when the latter has safety risks.
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Affiliation(s)
- Dong-Hao Zhou
- State Key Laboratory of Earth Surface Processes and Resource Ecology and MOE Key Laboratory for Biodiversity Science and Ecological Engineering, College of Life Sciences, Beijing Normal University, Beijing, China
| | - Quan-Guo Zhang
- State Key Laboratory of Earth Surface Processes and Resource Ecology and MOE Key Laboratory for Biodiversity Science and Ecological Engineering, College of Life Sciences, Beijing Normal University, Beijing, China
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Lafaurie M, Burdet C, Hammas K, Goldwirt L, Berçot B, Sauvageon H, Houze P, Fourmont M, Mentré F, Molina JM. Population pharmacokinetics and pharmacodynamics of imipenem in neutropenic adult patients. Infect Dis Now 2023; 53:104625. [PMID: 36174960 DOI: 10.1016/j.idnow.2022.09.020] [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: 07/04/2022] [Revised: 09/08/2022] [Accepted: 09/21/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Imipenem is recommended in patients with chemotherapy-induced febrile neutropenia. Although alterations of antibiotic pharmacokinetic parameters have been reported in such patients, little data is available on imipenem. METHODS Prospective, single-center, non-interventional pharmacokinetic cohort study in adults with chemotherapy-induced febrile neutropenia. Critically ill patients were excluded. Imipenem was administered as a 30-min infusion of 1000 mg/8h. Total imipenem plasma concentrations were assayed by high-performance liquid chromatography during neutropenia and just after neutrophil recovery. We estimated population pharmacokinetic parameters of imipenem by non-linear mixed-effect modelling using the SAEM algorithm. RESULTS Sixteen patients were included in the study, including nine women (56.3%), median age 37 years (range, 18.3; 78.3). Eight patients had an hematological malignancy (50.0%) and seven had a solid tumor (43.8%). Imipenem pharmacokinetics were best described by a one-compartment model with first-order elimination. Mean values for imipenem were: clearance 14.3L/h and 10.9L/h and volume of distribution 20.7L and 14.5 L during neutropenia and after recovery, respectively. Imipenem plasma area under the curve at steady state was reduced by 23% during neutropenia. However, all patients achieved a pharmacodynamic target of %fT>MIC ≥ 40% with a regimen of 1000 mg/8 h or 500 mg/6 h, for MICs up to 2 mg/L. The pharmacodynamics profile for a target of %fT > MIC = 100% was however less favorable with 500 mg/6 h or 1000 mg/8 h either during or after neutropenia. CONCLUSION Pharmacokinetic/pharmacodynamic goals for imipenem were similar in patients during and after neutropenia, despite reduced plasma exposure.
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Affiliation(s)
- M Lafaurie
- AP-HP, Hôpital Saint-Louis, Lariboisière, Département de Maladies Infectieuses et Tropicales, F-75010 Paris, France.
| | - C Burdet
- AP-HP, Hôpital Bichat, Département d'Épidémiologie, Biostatistique et Recherche Clinique, F-75018 Paris, France; Université de Paris, IAME, INSERM, F-75018 Paris, France
| | - K Hammas
- AP-HP, Hôpital Bichat, Département d'Épidémiologie, Biostatistique et Recherche Clinique, F-75018 Paris, France
| | - L Goldwirt
- AP-HP, Hôpital Saint-Louis, Laboratoire de Pharmacologie Biologique, F-75010 Paris, France
| | - B Berçot
- Université de Paris, IAME, INSERM, F-75018 Paris, France; AP-HP, Hôpital Saint-Louis, Service de Bactériologie, F-75010 Paris, France
| | - H Sauvageon
- AP-HP, Hôpital Saint-Louis, Laboratoire de Pharmacologie Biologique, F-75010 Paris, France; Université de Paris, UMR S976, INSERM, F-75006 Paris, France
| | - P Houze
- Université de Paris, UTCBS, CNRS UMR8258, INSERM U1022, Paris, France
| | - M Fourmont
- AP-HP, Hôpital Saint-Louis, Service d'hématologie, unité Adolescent et jeunes adultes, F-75010 Paris, France
| | - F Mentré
- AP-HP, Hôpital Bichat, Département d'Épidémiologie, Biostatistique et Recherche Clinique, F-75018 Paris, France; Université de Paris, IAME, INSERM, F-75018 Paris, France
| | - J M Molina
- AP-HP, Hôpital Saint-Louis, Lariboisière, Département de Maladies Infectieuses et Tropicales, F-75010 Paris, France; Université de Paris, UMR S976, INSERM, F-75006 Paris, France
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10
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Alzahrani AM, Hakami AY, AlAzmi A, Karim S, Ali AS, Burzangi AS, Alkreathy HM, Khan MA, Alzhrani RM, Basudan SS, Alzahrani YA. Augmented Renal Clearance and Hypoalbuminemia-Induced Low Vancomycin Trough Concentrations in Febrile Neutropenic Patients With Hematological Malignancies. Cureus 2022; 14:e29568. [DOI: 10.7759/cureus.29568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2022] [Indexed: 11/05/2022] Open
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11
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Saillard C, Legal PH, Furst S, Bisbal M, Servan L, Sannini A, Gonzalez F, Faucher M, Vey N, Blaise D, Chow-Chine L, Mokart D. Feasibility of Cyclosporine Prophylaxis Withdrawal in Critically Ill Allogenic Hematopoietic Stem Cell Transplant Patients Admitted to the Intensive Care Unit With No GVHD. Transplant Cell Ther 2022; 28:783.e1-783.e10. [DOI: 10.1016/j.jtct.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 11/12/2022]
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12
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Infection prevention requirements for the medical care of immunosuppressed patients: recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) at the Robert Koch Institute. GMS HYGIENE AND INFECTION CONTROL 2022; 17:Doc07. [PMID: 35707229 PMCID: PMC9174886 DOI: 10.3205/dgkh000410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In Germany, guidelines for hygiene in hospitals are given in form of recommendations by the Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, "KRINKO"). The KRINKO and its voluntary work are legitimized by the mandate according to § 23 of the Infection Protection Act (Infektionsschutzgesetz, "IfSG"). The original German version of this document was published in February 2021 and has now been made available to the international professional public in English. The guideline provides recommendations on infection prevention and control for immunocompromised individuals in health care facilities. This recommendation addresses not only measures related to direct medical care of immunocompromised patients, but also management aspects such as surveillance, screening, antibiotic stewardship, and technical/structural aspects such as patient rooms, air quality, and special measures during renovations.
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Bian X, Qu X, Zhang J, Nang SC, Bergen PJ, Tony Zhou Q, Chan HK, Feng M, Li J. Pharmacokinetics and pharmacodynamics of peptide antibiotics. Adv Drug Deliv Rev 2022; 183:114171. [PMID: 35189264 PMCID: PMC10019944 DOI: 10.1016/j.addr.2022.114171] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 01/23/2022] [Accepted: 02/16/2022] [Indexed: 01/05/2023]
Abstract
Antimicrobial resistance is a major global health challenge. As few new efficacious antibiotics will become available in the near future, peptide antibiotics continue to be major therapeutic options for treating infections caused by multidrug-resistant pathogens. Rational use of antibiotics requires optimisation of the pharmacokinetics and pharmacodynamics for the treatment of different types of infections. Toxicodynamics must also be considered to improve the safety of antibiotic use and, where appropriate, to guide therapeutic drug monitoring. This review focuses on the pharmacokinetics/pharmacodynamics/toxicodynamics of peptide antibiotics against multidrug-resistant Gram-negative and Gram-positive pathogens. Optimising antibiotic exposure at the infection site is essential for improving their efficacy and minimising emergence of resistance.
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Affiliation(s)
- Xingchen Bian
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China
| | - Xingyi Qu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; School of Pharmacy, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China; Key Laboratory of Clinical Pharmacology of Antibiotics, Shanghai, China; National Health Commission & National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Phase I Unit, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Sue C Nang
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Phillip J Bergen
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia
| | - Qi Tony Zhou
- Department of Industrial and Physical Pharmacy, College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Meiqing Feng
- School of Pharmacy, Fudan University, Shanghai, China
| | - Jian Li
- Biomedicine Discovery Institute and Department of Microbiology, Monash University, Melbourne, Australia.
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Abdul-Aziz MH, Brady K, Cotta MO, Roberts JA. Therapeutic Drug Monitoring of Antibiotics: Defining the Therapeutic Range. Ther Drug Monit 2022; 44:19-31. [PMID: 34750338 DOI: 10.1097/ftd.0000000000000940] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE In the present narrative review, the authors aimed to discuss the relationship between the pharmacokinetic/pharmacodynamic (PK/PD) of antibiotics and clinical response (including efficacy and toxicity). In addition, this review describes how this relationship can be applied to define the therapeutic range of a particular antibiotic (or antibiotic class) for therapeutic drug monitoring (TDM). METHODS Relevant clinical studies that examined the relationship between PK/PD of antibiotics and clinical response (efficacy and response) were reviewed. The review (performed for studies published in English up to September 2021) assessed only commonly used antibiotics (or antibiotic classes), including aminoglycosides, beta-lactam antibiotics, daptomycin, fluoroquinolones, glycopeptides (teicoplanin and vancomycin), and linezolid. The best currently available evidence was used to define the therapeutic range for these antibiotics. RESULTS The therapeutic range associated with maximal clinical efficacy and minimal toxicity is available for commonly used antibiotics, and these values can be implemented when TDM for antibiotics is performed. Additional data are needed to clarify the relationship between PK/PD indices and the development of antibiotic resistance. CONCLUSIONS TDM should only be regarded as a means to achieve the main goal of providing safe and effective antibiotic therapy for all patients. The next critical step is to define exposures that can prevent the development of antibiotic resistance and include these exposures as therapeutic drug monitoring targets.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Kara Brady
- Adult Intensive Care Unit and Pharmacy, The Prince Charles Hospital, Brisbane, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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15
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Pai MP, Crass RL. Translation of Pharmacodynamic Biomarkers of Antibiotic Efficacy in Specific Populations to Optimize Doses. Antibiotics (Basel) 2021; 10:antibiotics10111368. [PMID: 34827306 PMCID: PMC8614818 DOI: 10.3390/antibiotics10111368] [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: 09/29/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
Antibiotic efficacy determination in clinical trials often relies on non-inferiority designs because they afford smaller study sample sizes. These efficacy studies tend to exclude patients within specific populations or include too few patients to discern potential differences in their clinical outcomes. As a result, dosing guidance in patients with abnormal liver and kidney function, age across the lifespan, and other specific populations relies on drug exposure-matching. The underlying assumption for exposure-matching is that the disease course and the response to the antibiotic are similar in patients with and without the specific condition. While this may not be the case, clinical efficacy studies are underpowered to ensure this is true. The current paper provides an integrative review of the current approach to dose selection in specific populations. We review existing clinical trial endpoints that could be measured on a more continuous rather than a discrete scale to better inform exposure-response relationships. The inclusion of newer systemic biomarkers of efficacy can help overcome the current limitations. We use a modeling and simulation exercise to illustrate how an efficacy biomarker can inform dose selection better. Studies that inform response-matching rather than exposure-matching only are needed to improve dose selection in specific populations.
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Affiliation(s)
- Manjunath P. Pai
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Rm 2568, 428 Church St., Ann Arbor, MI 48109, USA
- Correspondence: ; Tel.: +1-734-647-0006
| | - Ryan L. Crass
- Ann Arbor Pharmacometrics Group, Ann Arbor, MI 48108, USA;
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Jantarathaneewat K, Apisarnthanarak A, Limvorapitak W, Weber DJ, Montakantikul P. Pharmacist-Driven Antibiotic Stewardship Program in Febrile Neutropenic Patients: A Single Site Prospective Study in Thailand. Antibiotics (Basel) 2021; 10:antibiotics10040456. [PMID: 33920541 PMCID: PMC8072986 DOI: 10.3390/antibiotics10040456] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 12/11/2022] Open
Abstract
The antibiotic stewardship program (ASP) is a necessary part of febrile neutropenia (FN) treatment. Pharmacist-driven ASP is one of the meaningful approaches to improve the appropriateness of antibiotic usage. Our study aimed to determine role of the pharmacist in ASPs for FN patients. We prospectively studied at Thammasat University Hospital between August 2019 and April 2020. Our primary outcome was to compare the appropriate use of target antibiotics between the pharmacist-driven ASP group and the control group. The results showed 90 FN events in 66 patients. The choice of an appropriate antibiotic was significantly higher in the pharmacist-driven ASP group than the control group (88.9% vs. 51.1%, p < 0.001). Furthermore, there was greater appropriateness of the dosage regimen chosen as empirical therapy in the pharmacist-driven ASP group than in the control group (97.8% vs. 88.7%, p = 0.049) and proper duration of target antibiotics in documentation therapy (91.1% vs. 75.6%, p = 0.039). The multivariate analysis showed a pharmacist-driven ASP and infectious diseases consultation had a favorable impact on 30-day infectious diseases-related mortality in chemotherapy-induced FN patients (OR 0.058, 95%CI:0.005–0.655, p = 0.021). Our study demonstrated that pharmacist-driven ASPs could be a great opportunity to improve antibiotic appropriateness in FN patients.
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Affiliation(s)
- Kittiya Jantarathaneewat
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand;
- Department of Pharmaceutical care, Faculty of Pharmacy, Thammasat University, Pathum Thani 12120, Thailand
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
| | - Wasithep Limvorapitak
- Division of Hematology, Faculty of Medicine, Thammasat University, Pathum Thani 12120, Thailand;
| | - David J. Weber
- School of Global Public Health, University of North Carolina, Gillings, Chapel Hill, NC 27599-7400, USA;
| | - Preecha Montakantikul
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand;
- Correspondence: ; Tel.: +66-0-2644-8694
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17
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Anforderungen an die Infektionsprävention bei der medizinischen Versorgung von immunsupprimierten Patienten. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 64:232-264. [PMID: 33394069 PMCID: PMC7780910 DOI: 10.1007/s00103-020-03265-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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18
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Contejean A, Jaffrelot L, Benaboud S, Tréluyer JM, Grignano E, Willems L, Gauzit R, Bouscary D, Gana I, Boujaafar S, Kernéis S, Hirt D. A meropenem pharmacokinetics model in patients with haematological malignancies. J Antimicrob Chemother 2020; 75:2960-2968. [DOI: 10.1093/jac/dkaa275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/19/2020] [Indexed: 02/03/2023] Open
Abstract
Abstract
Background
Optimal dosing of antibiotics is critical in immunocompromised patients suspected to have an infection. Data on pharmacokinetics (PK) of meropenem in patients with haematological malignancies are scarce.
Objectives
To optimize dosing regimens, we aimed to develop a PK population model for meropenem in this population.
Methods
Patients aged ≥18 years, hospitalized in the haematology department of our 1500 bed university hospital for a malignant haematological disease and who had received at least one dose of meropenem were eligible. Meropenem was quantified by HPLC. PK were described using a non-linear mixed-effect model and external validation performed on a distinct database. Monte Carlo simulations estimated the PTA, depending on renal function, duration of infusion and MIC. Target for free trough concentration was set at >4× MIC.
Results
Overall, 88 patients (181 samples) were included, 66 patients (75%) were in aplasia and median Modification of Diet in Renal Disease (MDRD) CLCR was 117 mL/min/1.73 m2 (range: 35–359). Initial meropenem dosing regimen ranged from 1 g q8h to 2 g q8h over 30 to 60 min. A one-compartment model with first-order elimination adequately described the data. Only MDRD CLCR was found to be significantly associated with CL. Only continuous infusion achieved a PTA of 100% whatever the MIC and MDRD CLCR. Short duration of infusion (<60 min) failed to reach an acceptable PTA, except for bacteria with MIC < 0.25 mg/L in patients with MDRD CLCR below 90 mL/min/1.73 m2.
Conclusions
In patients with malignant haematological diseases, meropenem should be administered at high dose (6 g/day) and on continuous infusion to reach acceptable trough concentrations.
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Affiliation(s)
- A Contejean
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - L Jaffrelot
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Benaboud
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - J -M Tréluyer
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
- CIC-1419 Inserm, Cochin-Necker, Paris, France
| | - E Grignano
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Université de Paris, Faculté de Médecine, Paris, France
| | - L Willems
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
| | - R Gauzit
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - D Bouscary
- Service d’Hématologie, AP-HP, Hôpital Cochin, Paris, France
- Université de Paris, Faculté de Médecine, Paris, France
| | - I Gana
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Boujaafar
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
| | - S Kernéis
- Université de Paris, Faculté de Médecine, Paris, France
- Equipe mobile d’infectiologie, AP-HP, Centre Université de Paris—Cochin, Paris, France
| | - D Hirt
- Université de Paris, Faculté de Médecine, Paris, France
- Service de Pharmacologie Clinique, AP-HP, Hôpital Cochin, Paris, France
- INSERM, U1018, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
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He N, Dong F, Liu W, Zhai S. A Systematic Review of Vancomycin Dosing in Patients with Hematologic Malignancies or Neutropenia. Infect Drug Resist 2020; 13:1807-1821. [PMID: 32606830 PMCID: PMC7305817 DOI: 10.2147/idr.s239095] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 05/04/2020] [Indexed: 12/20/2022] Open
Abstract
Objective To provide a comprehensive review of vancomycin dosing in patients with hematologic malignancies or neutropenia. Methods PubMed, Embase and the Cochrane Library were searched through April 2, 2020. Original studies relevant to vancomycin dosing regimen in adults with hematologic malignancies or neutropenia were included. No restriction was applied in study design and language. A descriptive analysis was performed. Results Twenty-three studies were included eventually, of which eighteen were case series studies, four were cohort studies and another one was a randomized controlled trial. Five case series studies made a clinical audit of conventional vancomycin dosing in patients with malignancies or neutropenia, showing that the proportion of patients with sub-therapeutic trough levels remained high, ranging from 32% to 88%. Seven case series studies and four cohort studies demonstrated that vancomycin clearance (CLva) tended to be higher in patients with hematologic malignancies or neutropenia, whereas volume of distribution (V) seemed to be comparable to the control group. Five studies proposed individualized initial dosing regimen per the pharmacokinetic changes; however, no prospective validation has been conducted in clinical setting. Additionally, four case series studies suggested that the correlation between vancomycin clearance and estimated creatinine clearance was relatively poor, bringing a great challenge to proper dosing strategy. A randomized controlled trial stated that therapeutic drug monitoring (TDM) of vancomycin could decrease the incidence of nephrotoxicity in immunocompromised febrile patients with hematologic malignancies. Conclusion The available evidence indicates that conventional vancomycin dosing leads to suboptimal concentration in patients with hematologic malignancy or neutropenia. TDM accompanied by pharmacokinetic interpretation can decrease the risk of nephrotoxicity. The individualization of the initial dosing regimen and mechanisms of augmented clearance require further research.
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Affiliation(s)
- Na He
- Department of Pharmacy, Peking University Third Hospital, Beijing, People's Republic of China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Science, Peking University, Beijing, People's Republic of China
| | - Fei Dong
- Department of Hematology, Peking University Third Hospital, Beijing, People's Republic of China
| | - Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, People's Republic of China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, People's Republic of China
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Derendorf H, Heinrichs T, Reimers T, Lebert C, Brinkmann A. Calculated initial parenteral treatment of bacterial infections: Pharmacokinetics and pharmacodynamics. GMS INFECTIOUS DISEASES 2020; 8:Doc17. [PMID: 32373442 PMCID: PMC7186811 DOI: 10.3205/id000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the third chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter features the pharmacokinetic and pharmacodynamics properties of the most frequently used antiinfective agents.
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Affiliation(s)
- Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Tobias Reimers
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, USA
| | | | - Alexander Brinkmann
- Klinik für Anästhesie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, Germany
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21
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Early Bayesian Dose Adjustment of Vancomycin Continuous Infusion in Children: a Randomized Controlled Trial. Antimicrob Agents Chemother 2019:AAC.01102-19. [PMID: 31591117 DOI: 10.1128/aac.01102-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Methicillin-resistant staphylococcal infections are a global burden. Area under the serum concentration-time curve to minimum inhibitory concentration (AUC/MIC) ratio is the pharmacokinetic (PK) parameter that best predicts vancomycin efficacy. Its therapeutic range is narrow, difficult to achieve because of a wide intersubject variability, especially in children, and is not routinely targeted since the AUC is rarely available. We investigated if an early Bayesian dose adjustment would increase the rate of vancomycin target attainment, in the first 24 hours of treatment (H24), in children.We conducted a single-centre randomized controlled trial in 4 pediatric departments of Necker-Enfants Malades hospital (Paris, France). Patients aged 3 months to 17 years for whom intravenous vancomycin was started were eligible and randomized in a 1:1 ratio: routine care were compared with an early vancomycin therapeutic drug monitoring (3h after treatment initiation) followed by an early Bayesian dose adjustment using a previously published population-based PK model that included age, bodyweight and serum creatinine as covariates. The primary outcome was the proportion of patients of each group achieving vancomycin therapeutic range at H24, defined by AUC0-24/MIC≥400 and AUC0-24 ≤800mg-h/L.Ninety-nine patients were enrolled: 49 were randomized to the Bayesian group and 50 to the control group. Modified intention-to-treat analysis included 82 patients: 85% of Bayesian group patients achieved H24 vancomycin target versus 57% of control group patients (p=0.007) with no difference regarding iatrogenic events. Early Bayesian dose adjustment increased the proportion of children achieving vancomycin target at H24, which may improve clinical outcomes of methicillin-resistant staphylococcal infections.
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Thorsted A, Kristoffersson AN, Maarbjerg SF, Schrøder H, Wang M, Brock B, Nielsen EI, Friberg LE. Population pharmacokinetics of piperacillin in febrile children receiving cancer chemotherapy: the impact of body weight and target on an optimal dosing regimen. J Antimicrob Chemother 2019; 74:2984-2993. [PMID: 31273375 PMCID: PMC6916132 DOI: 10.1093/jac/dkz270] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/22/2019] [Accepted: 05/28/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The β-lactam antibiotic piperacillin (in combination with tazobactam) is commonly chosen for empirical treatment of suspected bacterial infections. However, pharmacokinetic variability among patient populations and across ages leads to uncertainty when selecting a dosing regimen to achieve an appropriate pharmacodynamic target. OBJECTIVES To guide dosing by establishing a population pharmacokinetic model for unbound piperacillin in febrile children receiving cancer chemotherapy, and to assess pharmacokinetic/pharmacodynamic target attainment (100% fT > 1×MIC and 50% fT > 4×MIC) and resultant exposure, across body weights. METHODS Forty-three children admitted for 89 febrile episodes contributed 482 samples to the pharmacokinetic analysis. The typical doses required for target attainment were compared for various dosing regimens, in particular prolonged infusions, across MICs and body weights. RESULTS A two-compartment model with inter-fever-episode variability in CL, and body weight included through allometry, described the data. A high CL of 15.4 L/h (70 kg) combined with high glomerular filtration rate (GFR) values indicated rapid elimination and hyperfiltration. The target of 50% fT > 4×MIC was achieved for an MIC of 4.0 mg/L in a typical patient with extended infusions of 2-3 (q6h) or 3-4 (q8h) h, at or below the standard adult dose (75 and 100 mg/kg/dose for q6h and q8h, respectively). Higher doses or continuous infusion were needed to achieve 100% fT > 1×MIC due to the rapid piperacillin elimination. CONCLUSIONS The licensed dose for children with febrile neutropenia (80 mg/kg q6h as a 30 min infusion) performs poorly for attainment of fT>MIC pharmacokinetic/pharmacodynamic targets. Given the population pharmacokinetic profile, feasible dosing regimens with reasonable exposure are continuous infusion (100% fT > 1×MIC) or prolonged infusions (50% fT > 4×MIC).
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Affiliation(s)
- Anders Thorsted
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | - Sabine F Maarbjerg
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schrøder
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mikala Wang
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Brock
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Lim WXS, Chua WBB, Chua JM, Lee Q, Chan JW, Sultana R, Poh BH. A Retrospective Review of the Efficiency of First‐Dose Therapeutic Drug Monitoring of Gentamicin, Amikacin, and Vancomycin in the Pediatric Population. J Clin Pharmacol 2019; 60:7-15. [DOI: 10.1002/jcph.1509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/28/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Wan Xuan Selina Lim
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | | | - Jie Min Chua
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Qianyu Lee
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Jer Wei Chan
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
| | - Rehena Sultana
- Centre for Quantitative MedicineDuke‐National University of Singapore Singapore
| | - Bao Hui Poh
- Department of PharmacyKK Women's and Children's Hospital Singhealth Singapore
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Weber N, Jackson K, McWhinney B, Ungerer J, Kennedy G, Lipman J, Roberts JA. Evaluation of pharmacokinetic/pharmacodynamic and clinical outcomes with 6-hourly empiric piperacillin-tazobactam dosing in hematological malignancy patients with febrile neutropenia. J Infect Chemother 2019; 25:503-508. [DOI: 10.1016/j.jiac.2019.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 01/22/2019] [Accepted: 02/18/2019] [Indexed: 12/31/2022]
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Margolis E, Rosch JW. Fitness Landscape of the Immune Compromised Favors the Emergence of Antibiotic Resistance. ACS Infect Dis 2018; 4:1275-1277. [PMID: 30070470 DOI: 10.1021/acsinfecdis.8b00158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Antibiotic resistance can come at a high cost, both in terms of fitness for the pathogen and poorer outcomes for patients. The fitness landscape encountered by bacterial pathogens varies greatly throughout patient populations in terms of host immunity as well as the duration and spectrum of antibiotics encountered. Severely immunocompromised patients present a favorable environment for antibiotic resistance to emerge due to lack of immune-mediated competition and increased opportunities to evolve both on-target and compensatory mutations. Such patients may present unique pathways for antibiotic resistance to emerge.
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Affiliation(s)
- Elisa Margolis
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, United States
| | - Jason W. Rosch
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, Tennessee 38105, United States
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Validation of a Nomogram for Achieving Target Trough Concentration of Vancomycin: Accuracy in Patients With Augmented Renal Function. Ther Drug Monit 2018; 40:693-698. [PMID: 30157096 DOI: 10.1097/ftd.0000000000000562] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adjustment of initial vancomycin (VCM) dosage has been recommended on the basis of the renal function nomogram in therapeutic drug monitoring guidelines in Japan. However, this nomogram has not been clinically validated, and few studies have focused on its usefulness in patients with risk of augmented renal function. Therefore, this study aimed to evaluate the validity of the VCM nomogram and the association between patient conditions related to augmented renal function and its accuracy. METHODS In this retrospective study, we screened data of 398 patients who received VCM and had estimated glomerular filtration rates ≥30 mL·min·1.73 m. Patients who met nomogram dosing criteria were categorized into a nomogram group, and the associations of age, renal function, and individual conditions such as febrile neutropenia, solid tumor, blood cancer, and brain injury with subtherapeutic concentrations (<10.0 mcg/mL) of VCM were evaluated. RESULTS In total, 177 patients were categorized into the nomogram group, and 83 (47%), 81 (46%), and 13 patients (7%) had VCM trough concentrations of 10-20, <10, and >20 mcg/mL, respectively. Age <50 years was only significantly associated with subtherapeutic trough concentrations. Specific conditions of patients such as febrile neutropenia, solid tumor, and blood cancer were associated with elevated VCM clearance; however, there was no decline in trough VCM concentrations regardless of the presence of the specific conditions. CONCLUSIONS The Japanese VCM dosing nomogram was effective in minimizing the number of instances of supratherapeutic VCM serum concentrations; however, it lacked accuracy in achieving target trough concentrations. The accuracy of the nomogram could be enhanced by categorizing patients according to age. Nevertheless, this study provides novel evidence of the usefulness of this nomogram in avoiding subtherapeutic concentrations of VCM in patients with risk factors for augmented renal clearance.
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De-escalation and discontinuation strategies in high-risk neutropenic patients: an interrupted time series analyses of antimicrobial consumption and impact on outcome. Eur J Clin Microbiol Infect Dis 2018; 37:1931-1940. [PMID: 30051357 DOI: 10.1007/s10096-018-3328-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 07/10/2018] [Indexed: 02/06/2023]
Abstract
Febrile neutropenia (FN) is the main reason for antibiotic prescription in hematology wards where, on the other hand, antibiotic stewardship (AS) is poorly explored. The objectives of the present study were to evaluate (1) the impact of an AS intervention on antibiotic consumption and (2) the applicability and acceptance rate of the intervention and its clinical impact. A persuasive AS intervention based on European Conference on Infection in Leukaemia (ECIL) guidelines for FN was implemented in a high-risk hematology ward in a tertiary referral public university hospital. This included the creation and diffusion of flow charts on de-escalation and discontinuation of antibiotics for FN, and the introduction in the team of a doctor dedicated to the implementation of flow charts and to antibiotic prescription revision. All consecutive patients receiving antibiotics during hospitalization were included. A segmented linear regression model was performed for the evaluation of antibiotic consumption, taking into account 1-year pre-intervention period and 6-month intervention period. Overall, 137 consecutive antibiotic prescriptions were re-evaluated, 100 prescriptions were for FN. A significant reduction of the level of carbapenem consumption was observed during the intervention period (level change (estimate coefficient ± standard error) = - 135.28 ± 59.49; p = 0.04). Applicability and acceptability of flow charts were high. No differences in terms of intensive care unit transfers, bacteremia incidence, and mortality were found. A persuasive AS intervention in hematology significantly reduced carbapenem consumption without affecting outcome and was well accepted. This should encourage further applications of ECIL guidelines for FN.
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Okada A, Kariya M, Irie K, Okada Y, Hiramoto N, Hashimoto H, Kajioka R, Maruyama C, Kasai H, Hamori M, Nishimura A, Shibata N, Fukushima K, Sugioka N. Population Pharmacokinetics of Vancomycin in Patients Undergoing Allogeneic Hematopoietic Stem-Cell Transplantation. J Clin Pharmacol 2018; 58:1140-1149. [DOI: 10.1002/jcph.1106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/25/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Akira Okada
- Department of Clinical Pharmacokinetics; Faculty of Pharmaceutical Sciences; Kobe Gakuin University; Chuo-ku Kobe Japan
| | - Misato Kariya
- Department of Hospital Pharmacy; Kobe Minimally Invasive Cancer Center; Chuo-ku; Kobe Japan
- Department of Hospital Pharmacy; Institute of Biomedical Research and Innovation Hospital; Chuo-ku; Kobe Japan
| | - Kei Irie
- Department of Hospital Pharmacy; Institute of Biomedical Research and Innovation Hospital; Chuo-ku; Kobe Japan
| | - Yutaka Okada
- Department of Hospital Pharmacy; Institute of Biomedical Research and Innovation Hospital; Chuo-ku; Kobe Japan
| | - Nobuhiro Hiramoto
- Department of Cell Therapy; Institute of Biomedical Research and Innovation Hospital; Chuo-ku; Kobe Japan
| | - Hisako Hashimoto
- Department of Cell Therapy; Institute of Biomedical Research and Innovation Hospital; Chuo-ku; Kobe Japan
| | - Ryosuke Kajioka
- Department of Clinical Pharmacokinetics; Faculty of Pharmaceutical Sciences; Kobe Gakuin University; Chuo-ku Kobe Japan
| | - Chika Maruyama
- Department of Clinical Pharmacokinetics; Faculty of Pharmaceutical Sciences; Kobe Gakuin University; Chuo-ku Kobe Japan
| | | | - Mami Hamori
- Depertment of Biopharmaceutics; Faculty of Pharmaceutical Science; Doshisha Women's College of Liberal Arts; Kyo-tanabe Kyoto Japan
| | - Asako Nishimura
- Depertment of Biopharmaceutics; Faculty of Pharmaceutical Science; Doshisha Women's College of Liberal Arts; Kyo-tanabe Kyoto Japan
| | - Nobuhito Shibata
- Depertment of Biopharmaceutics; Faculty of Pharmaceutical Science; Doshisha Women's College of Liberal Arts; Kyo-tanabe Kyoto Japan
| | - Keizo Fukushima
- Department of Clinical Pharmacokinetics; Faculty of Pharmaceutical Sciences; Kobe Gakuin University; Chuo-ku Kobe Japan
| | - Nobuyuki Sugioka
- Department of Clinical Pharmacokinetics; Faculty of Pharmaceutical Sciences; Kobe Gakuin University; Chuo-ku Kobe Japan
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Augmented Renal Clearance in Patients With Febrile Neutropenia is Associated With Increased Risk for Subtherapeutic Concentrations of Vancomycin. Ther Drug Monit 2017; 38:706-710. [PMID: 27681114 DOI: 10.1097/ftd.0000000000000346] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Augmented renal clearance (ARC) has frequently been observed in critically ill patients. The risk factors for ARC in patients, including those in the general ward, and their influences on vancomycin (VCM) treatment remain unclear. The aims of this study were to investigate the risk factors for ARC and to evaluate the influence of ARC on the pharmacokinetic parameters of VCM. METHODS This study included a total of 292 patients with VCM treatment who had normal serum creatinine concentrations. ARC was defined by an estimated creatinine clearance ≥130 mL·min·1.73 m. The risk factors for ARC were determined with stepwise logistic regression analysis. The pharmacokinetic parameters of VCM were estimated through the Bayesian method using a 2-compartment model. RESULTS ARC was observed in 48 patients (16.4%). Age ≤65 years [odds ratio (OR): 5.77; 95% CI: 2.89-11.97; P < 0.0001], brain injury (OR: 5.11; 95% CI: 1.49-17.57; P = 0.0086), febrile neutropenia (OR: 2.76; 95% CI: 1.11-6.67; P = 0.0254), and a mean volume of infusion fluid ≥1500 mL/d (OR: 2.53; 95% CI: 1.27-5.16; P = 0.0091) were independent risk factors for the occurrence of ARC. The patients with ARC exhibited higher VCM clearance values than the non-ARC patients. The median trough serum concentrations of VCM were 7.4 (interquartile range: 5.2-11.6) mcg/mL in the ARC patients and 12.2 (8.9-16.3) mcg/mL in the non-ARC patients (P < 0.0001). Subtherapeutic trough concentrations of VCM (<10.0 mcg/mL) were found in 68.8% of the ARC patients and in 32.8% of the non-ARC patients (P < 0.0001). CONCLUSIONS This observational study investigated the influence of febrile neutropenia on the emergency of ARC for the first time. ARC was strongly associated with VCM pharmacokinetics, and two-thirds of the ARC patients had subtherapeutic VCM concentrations. In patients with ARC, individualized dosing regimens are required to achieve the target trough concentration.
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Using Population Pharmacokinetic Modeling and Monte Carlo Simulations To Determine whether Standard Doses of Piperacillin in Piperacillin-Tazobactam Regimens Are Adequate for the Management of Febrile Neutropenia. Antimicrob Agents Chemother 2017; 61:AAC.00311-17. [PMID: 28807922 DOI: 10.1128/aac.00311-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 07/30/2017] [Indexed: 01/08/2023] Open
Abstract
Changes in the pharmacokinetics of piperacillin in febrile neutropenic patients have been reported to result in suboptimal exposures. This study aimed to develop a population pharmacokinetic model for piperacillin and perform dosing simulation to describe optimal dosing regimens for hematological malignancy patients with febrile neutropenia. Concentration-time data were obtained from previous prospective observational pharmacokinetic and interventional therapeutic drug monitoring studies. Nonparametric population pharmacokinetic analysis and Monte Carlo dosing simulations were performed with the Pmetrics package for R. A two-compartment model, with between-subject variability for clearance (CL), adequately described the data from 37 patients (21 males, age of 59 ± 12 years [means ± standard deviations] and weight of 77 ± 16 kg). Parameter estimates were CL of 18.0 ± 4.8 liters/h, volume of distribution of the central compartment of 14.3 ± 7.3 liters, rate constant for piperacillin distribution from the central to peripheral compartment of 1.40 ± 1.35 h-1, and rate constant for piperacillin distribution from the peripheral to central compartment of 4.99 ± 7.81 h-1 High creatinine clearance (CLCR) was associated with reduced probability of target attainment (PTA). Extended and continuous infusion regimens achieved a high PTA of >90% for an unbound concentration of piperacillin remaining above the MIC (fT>MIC) of 50%. Only continuous regimens achieved >90% PTA for 100% fT>MIC when CLCR was high. The cumulative fraction of response (FTA, for fractional target attainment) was suboptimal (<85%) for conventional regimens for both empirical and directed therapy considering 50% and 100% fT>MIC FTA was maximized with prolonged infusions. Overall, changes in piperacillin pharmacokinetics and the consequences on therapeutic dosing requirements appear similar to those observed in intensive care patients. Guidelines should address the altered dosing needs of febrile neutropenic patients exhibiting high CLCR or with known/presumed infections from high-MIC bacteria.
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Chung MK, Kim IJ, Lee J. Prevalence and Risk Factors Associated with Neutropenia in Hospitalized Patients with Systemic Lupus Erythematosus. JOURNAL OF RHEUMATIC DISEASES 2017. [DOI: 10.4078/jrd.2017.24.4.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Min Kyung Chung
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - In Je Kim
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jisoo Lee
- Division of Rheumatology, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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Neutropenia is independently associated with sub-therapeutic serum concentration of vancomycin. Clin Chim Acta 2016; 465:106-111. [PMID: 28025029 DOI: 10.1016/j.cca.2016.12.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 12/04/2016] [Accepted: 12/21/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND We aimed to identify the impact of the presence of neutropenia on serum vancomycin concentration (SVC). METHODS A retrospective study was conducted from January 2005 to December 2015. The study population was comprised of adult patients who were performed serum concentration of vancomycin. Patients with renal failure or using non-conventional dosages of vancomycin were excluded. RESULTS A total of 1307 adult patients were included in this study, of whom 163 (12.4%) were neutropenic. Patients with neutropenia presented significantly lower SVCs than non-neutropenic patients (P<0.0001). Multiple linear regressions showed significant association between neutropenia and trough SVC (beta coefficients, -2.351; P=0.004). Multiple logistic regression analysis also revealed a significant association between sub-therapeutic vancomycin concentrations (trough SVC values<10mg/l) and neutropenia (odds ratio, 1.75, P=0.029) CONCLUSIONS: The presence of neutropenia is significantly associated with low SVC, even after adjusting for other variables. Therefore, neutropenic patients had a higher risk of sub-therapeutic SVC compared with non-neutropenic patients. We recommended that vancomycin therapy should be monitored with TDM-guided optimization of dosage and intervals, especially in neutropenic patients.
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Aitken SL, Kontoyiannis DP, DePombo AM, Bhatti MM, Tverdek FP, Gettys SC, Nicolau DP, Nunez CA. Use of Ceftolozane/Tazobactam in the Treatment of Multidrug-resistant Pseudomonas aeruginosa Bloodstream Infection in a Pediatric Leukemia Patient. Pediatr Infect Dis J 2016; 35:1040-2. [PMID: 27254038 DOI: 10.1097/inf.0000000000001228] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Multidrug-resistant Pseudomonas aeruginosa is of increasing concern in pediatric patients. Ceftolozane/tazobactam is a novel cephalosporin/β-lactamase inhibitor combination with activity against multidrug-resistant Pseudomonas; however, no data exist on its use in children. This report summarizes the treatment of a multidrug-resistant P. aeruginosa bloodstream infection in a pediatric leukemia patient with ceftolozane/tazobactam and provides the first description of its pharmacokinetics in pediatrics.
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Affiliation(s)
- Samuel L Aitken
- From the *Division of Pharmacy, †Department of Infectious Diseases, Infection Control, and Employee Health, ‡Department of Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas; §Center for Anti-infective Research and Development, Hartford Hospital, Hartford, Connecticut; and ¶Department of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas
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Augmented Renal Clearance in Pediatric Patients With Febrile Neutropenia Associated With Vancomycin Clearance. Ther Drug Monit 2016; 38:393-7. [DOI: 10.1097/ftd.0000000000000270] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Taghizadeh-Ghehi M, Rezaee S, Gholami K, Hadjibabaie M. Predictive performance of Vancomycin population pharmacokinetic models in Iranian patients underwent hematopoietic stem cell transplantation. J Res Pharm Pract 2015; 4:129-34. [PMID: 26311080 PMCID: PMC4548431 DOI: 10.4103/2279-042x.162357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objective: Many hematopoietic stem cell transplantation (HSCT) patients receive vancomycin empirically during febrile neutropenia. There are several models for estimation of vancomycin pharmacokinetic parameters and calculation of initial dosing regimen accordingly. However, the performance of these methods in HSCT patients remained to be evaluated. The aim of the study was to determine which of the vancomycin population pharmacokinetic methods best fit Iranian HSCT patients. Methods: In order to evaluate predicted performance of seven vancomycin population pharmacokinetic models, the pharmacokinetic parameters of patients were estimated using each model's equations. Then the predicted steady-state trough vancomycin concentration was calculated based on each model's parameters and using a formula based on Sawchuk–Zaske method. The predicted steady-state trough vancomycin concentration and the real measured concentrations were compared to see which method was the most precise and least biased using mean squared error (MSE) and mean prediction error (ME) respectively. Findings: Forty-six patients (65% men) were included in the study. Calculated metrics showed a range of 38% under-prediction bias with Rodvold to 34% over-prediction bias with Matzke and Burton models. Birt and revised Burton methods showed no significant bias (ME [95% confidence interval (CI)]: –0.067 [–0.235–0.101] and 0.066 [–0.105–0.238]). Birt and revised Burton were not different significantly considering MSE (95% CI) of 0.385 (0.227–0.544) and 0.401 (0.255–0.546), respectively. Comparisons of precision with naive predictors revealed a delta MSE (95% CI) of –0.128 (–1.379–1.890) for Birt and 0.026 (–0.596–0.940) for revised Burton models. Conclusion: Although the Birt and Burton revised methods performed well, none of the studied models showed acceptable performance to be implemented as a routine method for initial dose calculation in HSCT patients. A vancomycin pharmacokinetic model specific for this high-risk subpopulation of Iranian patients should be designed and validated.
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Affiliation(s)
- Maryam Taghizadeh-Ghehi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Rezaee
- Department of Pharmaceutics, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Kheirollah Gholami
- Research Center for Rational Use of Drugs and Clinical Pharmacy Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Molouk Hadjibabaie
- Research Center for Rational Use of Drugs and Clinical Pharmacy Department, Tehran University of Medical Sciences, Tehran, Iran
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Adequacy of high-dose cefepime regimen in febrile neutropenic patients with hematological malignancies. Antimicrob Agents Chemother 2015; 59:5463-9. [PMID: 26124158 DOI: 10.1128/aac.00389-15] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 06/11/2015] [Indexed: 01/21/2023] Open
Abstract
While guidelines recommend empirical cefepime therapy in febrile neutropenia, the mortality benefit of cefepime has been controversial. In light of this, recent reports on pharmacokinetic changes for several antibiotics in febrile neutropenia and the consequent suboptimal exposure call for a pharmacokinetic/pharmacodynamic evaluation of current dosing. This study aimed to assess pharmacokinetic/pharmacodynamic target attainment from a 2-g intravenous (i.v.) every 8 h (q8h) cefepime regimen in febrile neutropenic patients with hematological malignancies. Cefepime plasma concentrations were measured in the 3rd, 6th, and 9th dosing intervals at 60% of the interval and/or trough point. The selected pharmacokinetic/pharmacodynamic targets were the proportion of the dosing interval (60% and 100%) for which the free drug concentration remains above the MIC (fT>MIC). Target attainment was assessed in reference to the MIC of isolated organisms if available or empirical breakpoints if not. The percentage of fT>MIC was also estimated by log-linear regression analysis. All patients achieved >60% fT>MIC in the 3rd and 6th dosing intervals. A 100% fT>MIC was not attained in 6/12, 4/10, and 4/9 patients in the 3rd, 6th, and 9th dose intervals, respectively, or in 14/31 (45%) of the dosing intervals investigated. On the other hand, 29/31 (94%) of trough concentrations were at or above 4 mg/liter. In conclusion, for patients with normal renal function, a high-dose 2-g i.v. q8h cefepime regimen appears to provide appropriate exposure if the MIC of the organism is ≤4 mg/liter but may fail to cover less susceptible organisms.
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Ogawara D, Fukuda M, Ueno S, Ohue Y, Takemoto S, Mizoguchi K, Nakatomi K, Nakamura Y, Obase Y, Honda T, Tsukamoto K, Ashizawa K, Oka M, Kohno S. Drug fever after cancer chemotherapy is most commonly observed on posttreatment days 3 and 4. Support Care Cancer 2015; 24:615-619. [PMID: 26108172 DOI: 10.1007/s00520-015-2820-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 06/15/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND This study was undertaken to analyze the characteristics of fever after cancer chemotherapy in order to reduce unnecessary medical care. METHODS Retrospectively, 1016 consecutive cycles of cancer chemotherapy were analyzed. Fever was defined as a temperature of ≥ 37.5 °C lasting for 1 h. Age, sex, tumor histology, the treatment regimen, the timing of fever onset, the number of days for which the fever persisted, the cause of the fever, the presence or absence of radiotherapy, and the use of granulocyte colony-stimulating factor (G-CSF) were examined. RESULTS The patients included 748 males and 268 females (median age = 68, range = 29-88), of whom 949, 52, and 15 were suffering from lung cancer, malignant pleural mesothelioma, and other diseases, respectively. Fever was observed in 367 cycles (36 %), including 280 cycles (37 %) involving males and 87 cycles (32 %) involving females. Fever occurred most commonly in the first cycles and was higher than later cycles (41 vs. 30 %, p < 0.001). Fever occurred most frequently on posttreatment days 4 (8 %), 3 (7 %), and 12 (7 %), and the distribution of fever episodes exhibited two peaks on posttreatment days 3 and 4 and 10-14. Fever on posttreatment days 3 and 4 was most commonly observed in patients treated with gemcitabine (20 %) or docetaxel (18 %). The causes of fever included infection (47 %; including febrile neutropenia [24 %]), adverse drug effects (24 %), unknown causes (19 %), and tumors (7 %). Radiotherapy led to a significant increase in the frequency of fever (46 vs. 34 %, p < 0.001). Thirty-three percent of patients received G-CSF, and the incidence ratios of fever in patients who received G-CSF were higher than those who did not receive G-CSF (44 vs. 31 %, p < 0.001). CONCLUSION The febrile episodes that occurred on posttreatment days 3 and 4 were considered to represent adverse drug reactions after cancer chemotherapy. Physicians should be aware of this feature of chemotherapy-associated fever and avoid unnecessary examination and treatments including prescribing antibiotics.
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Affiliation(s)
- Daiki Ogawara
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Minoru Fukuda
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan.
- Clinical Oncology Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Shiro Ueno
- Department of Respiratory Medicine, Ikeda Hospital, Kagoshima, Japan
| | - Yoshihiro Ohue
- Department of Respiratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Shinnosuke Takemoto
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Kosuke Mizoguchi
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Katsumi Nakatomi
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yoichi Nakamura
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yasushi Obase
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Takuya Honda
- Clinical Oncology Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Kazuhiro Tsukamoto
- Department of Pharmacotherapeutics, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kazuto Ashizawa
- Clinical Oncology Center, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Mikio Oka
- Department of Respiratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Shigeru Kohno
- Second Department of Internal Medicine, Nagasaki University Hospital, Nagasaki, Japan
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Stockmann C, Roberts JK, Yu T, Constance JE, Knibbe CAJ, Spigarelli MG, Sherwin CMT. Vancomycin pharmacokinetic models: informing the clinical management of drug-resistant bacterial infections. Expert Rev Anti Infect Ther 2015; 12:1371-88. [PMID: 25301231 DOI: 10.1586/14787210.2014.966081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This review aims to critically evaluate the pharmacokinetic literature describing the use of vancomycin in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections. Guidelines recommend that trough concentrations be used to guide vancomycin dosing for the treatment of MRSA infections; however, numerous in vitro, animal model and clinical studies have demonstrated that the therapeutic effectiveness of vancomycin is best described by the area under the concentration versus time curve (AUC) divided by the minimum inhibitory concentration (MIC) of the infecting organism (AUC/MIC). Among patients with lower respiratory tract infections, an AUC/MIC ≥400 was associated with a superior clinical and bacteriological response. Similarly, patients with MRSA bacteremia who achieved an Etest AUC/MIC ≥320 within 48 h were 50% less likely to experience treatment failure. For other patient populations and different clinical syndromes (e.g., children, the elderly, patients with osteomyelitis, etc.), pharmacokinetic/pharmacodynamic studies and prospective clinical trials are needed to establish appropriate therapeutic targets.
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Affiliation(s)
- Chris Stockmann
- Department of Pediatrics, Division of Clinical Pharmacology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, Utah 84108, USA
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Sime FB, Roberts MS, Tiong IS, Gardner JH, Lehman S, Peake SL, Hahn U, Warner MS, Roberts JA. Can therapeutic drug monitoring optimize exposure to piperacillin in febrile neutropenic patients with haematological malignancies? A randomized controlled trial. J Antimicrob Chemother 2015; 70:2369-75. [PMID: 25953805 DOI: 10.1093/jac/dkv123] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/11/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The objectives of this study were to describe piperacillin exposure in febrile neutropenia patients and determine whether therapeutic drug monitoring (TDM) can be used to increase the achievement of pharmacokinetic (PK)/pharmacodynamic (PD) targets. METHODS In a prospective randomized controlled study (Australian New Zealand Registry, ACTRN12615000086561), patients were subjected to TDM for 3 consecutive days. Dose was adjusted in the intervention group to achieve a free drug concentration above the MIC for 100% of the dose interval (100% fT>MIC), which was also the primary outcome measure. The secondary PK/PD target was 50% fT>MIC. Duration of fever and days to recovery from neutropenia were recorded. RESULTS Thirty-two patients were enrolled. Initially, patients received 4.5 g of piperacillin/tazobactam every 8 h or every 6 h along with gentamicin co-therapy in 30/32 (94%) patients. At the first TDM, 7/32 (22%) patients achieved 100% fT>MIC and 12/32 (38%) patients achieved 50% fT>MIC. Following dose adjustment, 11/16 (69%) of intervention patients versus 3/16 (19%) of control patients (P = 0.012) attained 100% fT>MIC, and 15/16 (94%) of intervention patients versus 5/16 (31%) of control patients (P = 0.001) achieved 50% fT>MIC. After the third TDM, the proportion of patients attaining 100% fT>MIC improved from a baseline 3/16 (19%) to 11/15 (73%) in the intervention group, while it declined from 4/16 (25%) to 1/15 (7%) in the control group. No difference was noted in the duration of fever and days to recovery from neutropenia. CONCLUSIONS Conventional doses of piperacillin/tazobactam may not offer adequate piperacillin exposure in febrile neutropenic patients. TDM provides useful feedback of dosing adequacy to guide dose optimization.
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Affiliation(s)
- Fekade Bruck Sime
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia Therapeutics Research Centre, Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, Australia Therapeutics Research Centre, School of Medicine, University of Queensland, Brisbane, Australia
| | - Ing Soo Tiong
- Department of Haematology/Oncology, The Queen Elizabeth Hospital, Adelaide, Australia SA Pathology and the University of Adelaide, Adelaide, Australia
| | - Julia H Gardner
- Department of Haematology/Oncology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Sheila Lehman
- Department of Haematology/Oncology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Sandra L Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Uwe Hahn
- Department of Haematology/Oncology, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Morgyn S Warner
- SA Pathology and the University of Adelaide, Adelaide, Australia
| | - Jason A Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia Burns, Trauma, and Critical Care Research Centre, University of Queensland, Herston, Brisbane, Queensland, Australia Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Population pharmacokinetics and dosing simulations of imipenem in serious bacteraemia in immunocompromised patients with febrile neutropenia. J Pharmacol Sci 2015; 127:164-9. [DOI: 10.1016/j.jphs.2014.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/01/2014] [Accepted: 12/02/2014] [Indexed: 11/23/2022] Open
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Gyssens IC, Kern WV, Livermore DM. The role of antibiotic stewardship in limiting antibacterial resistance among hematology patients. Haematologica 2014; 98:1821-5. [PMID: 24323982 DOI: 10.3324/haematol.2013.091769] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Goulenok T, Fantin B. Antimicrobial treatment of febrile neutropenia: pharmacokinetic-pharmacodynamic considerations. Clin Pharmacokinet 2014; 52:869-83. [PMID: 23807657 DOI: 10.1007/s40262-013-0086-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with cancer or hematologic diseases are particularly at risk of infection leading to high morbidity, mortality and costs. Extensive data show that optimization of the administration of antimicrobials according to their pharmacokinetic and pharmacodynamic parameters improves clinical outcome. Evidence is growing that when pharmacokinetic and pharmacodynamic parameters are used to target not only clinical cure but also eradication, the selection resistance is also contained. This is of particular importance in patients with neutropenia in whom increasing rates of drug-resistant Gram-negative bacteria have been reported, particularly Pseudomonas aeruginosa. Based on experimental and clinical studies, pharmacokinetic and pharmacodynamic parameters are discussed in this review for each antibiotic used in febrile neutropenia in order to help physicians improve dosing and optimization of antimicrobial agents.
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Affiliation(s)
- Tiphaine Goulenok
- Internal Medicine Department, Beaujon Hospital, APHP and University Paris Diderot, Sorbonne Paris Cité, Paris, France
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Altered pharmacokinetics of piperacillin in febrile neutropenic patients with hematological malignancy. Antimicrob Agents Chemother 2014; 58:3533-7. [PMID: 24687508 DOI: 10.1128/aac.02340-14] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study assessed the pharmacokinetics and dosing adequacy of piperacillin in febrile neutropenic patients after the first dose. Pharmacokinetic analysis was performed using noncompartmental methods. We observed an elevated volume of distribution (29.7 ± 8.0 liters [mean ± standard deviation]) and clearance (20.2 ± 7.5 liters/h) compared to data from other patient populations. Antibiotic exposure did not consistently result in therapeutic targets. We conclude that alternative dosing strategies guided by therapeutic drug monitoring may be required to optimize exposure.
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An evaluation of the association of leukopenia and severe infection in patients with systemic lupus erythematosus. J Clin Rheumatol 2013; 19:115-20. [PMID: 23519174 DOI: 10.1097/rhu.0b013e318289bb9b] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Leukopenia is a common finding in systemic lupus erythematosus (SLE) and may contribute to severe infections. OBJECTIVES The objectives of this study were to determine the prevalence of leukopenia in SLE patients and examine the association between these conditions and severe infections noting the risk factor of severe infections. METHODS This study was a prospective inception lupus cohort of newly diagnosed SLE patients seen between May 2007 and June 2011. Only cases that had been observed for a minimum of 1 year or died during the study were included. RESULTS There were 89 SLE patients (92% females), with their mean (SD) age and disease duration at the study entry of 31.7 (12.2) years and 2.4 (2.9) months. Leukopenia was found at the diagnosis in 51.6% of the cases. The cumulative prevalence of leukopenia, lymphopenia, and neutropenia was observed in 57.3%, 96.6%, and 60.7%, respectively. Persistent lymphopenia, noted continuously for more than or equal to 75% of the observation period, was found in 41.6%, but there was no persistent neutropenia. The incidence rate of severe infection was 12.4 per 100 patient-years. There was no difference of severe infection-free survival rate between patients who ever and never had leukopenia. In the multivariate analysis, using cyclophosphamide was the independent predictor for severe infection in SLE (hazard ratio, 2.73; 95% confidence interval, 1.10-6.77). CONCLUSIONS Leukopenia was common in SLE but usually not persistent. In this study, the presence of leukopenia at any time was not the risk factor for severe infection in SLE. Cyclophosphamide was the important predictor for severe infection in SLE.
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Lee SW, Park MC, Lee SK, Park YB. Adjusted neutropenia is associated with early serious infection in systemic lupus erythematosus. Mod Rheumatol 2013; 23:509-15. [DOI: 10.1007/s10165-012-0666-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 05/08/2012] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW Febrile neutropenia presents a clinical challenge in which timely and appropriate antibiotic exposure is crucial. In the context of altered pharmacokinetics and rising bacterial resistance, standard antibiotic doses are unlikely to be sufficient. This review explores the potential utility of altered dosing approaches of β-lactam antibiotics to optimize treatment in febrile neutropenia. RECENT FINDINGS There is a dynamic relationship between the antibiotic, the infecting pathogen, and the host. Great advancements have been made in the understanding of the pharmacokinetic changes in critical illness and the pharmacodynamic relationships of antibiotics in these settings. SUMMARY Antibiotic treatment in febrile neutropenia is becoming increasingly difficult. Patients are of higher acuity, receive more intensive chemotherapy regimens leading to prolonged neutropenia, and are often exposed to multiple antibiotic courses. These patients display significant variability in antibiotic clearances and increases in volume of distribution compared with standard ward-based patients. Rising antibiotic resistance and a lack of new antibiotics in production have prompted alternative dosing strategies based on pharmacokinetic/pharmacodynamic data, such as extended or continuous infusions of β-lactam antibiotics, to maximize the likelihood of treatment success. A definitive study that describes a mortality benefit of such dosing regimens remains elusive and the theoretical advantages require testing in well designed clinical trials.
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Stein GE, Kulhanek G, Smith CL, Kuti JL, Nicolau DP, Scharmen A, Farnum C, Tran M, Kalra A, Havlichek DH. Pharmacokinetics and monte carlo simulations of doripenem in patients with febrile neutropenia. Ann Pharmacother 2012; 46:1281-6. [PMID: 23012385 DOI: 10.1345/aph.1r097] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Doripenem is a group 2 carbapenem with enhanced in vitro activity against gram-negative bacteria including Pseudomonas aeruginosa. There is a paucity of pharmacokinetic/pharmacodynamic data on doripenem in patients with febrile neutropenia. OBJECTIVE To conduct a pharmacokinetic evaluation of 2 doses of doripenem in patients with febrile neutropenia and provide probability estimates of attaining effective drug exposure against common gram-negative pathogens. METHODS We obtained multiple blood samples from 12 adults with febrile neutropenia who were receiving either 500 mg or 1000 mg of intravenous doripenem over 4 hours every 8 hours. Following at least 2 doses, serum concentrations were measured in each subject at 1, 4, 6, and 8 hours after initiation of a dose by a validated high-performance liquid chromatography assay. The derived pharmacokinetic parameters from these serum levels were used to perform a 5000-patient Monte Carlo simulation against bacteria with minimal inhibitory concentrations (MICs) of 0.008-64 mg/L to determine probability estimates of the time in which unbound drug concentrations remain above the MIC (fT(>MIC)). RESULTS The mean pharmacokinetic parameters in these patients were a volume of distribution of 43.9 L, an elimination rate constant of 0.37 h(-1), a total clearance of 14.4 L/h, and an area under the concentration-time curve of 57.6 mg•h/L. An optimal probability of target attainment (40% fT(>MIC)) of 90% was obtained against bacteria with MICs ≤2 mg/L and ≤4 mg/L with 500-mg and 1000-mg doses, respectively. Adverse events associated with doripenem were not observed. CONCLUSIONS The findings from this analysis of doripenem suggest that higher doses, as well as prolonged infusions, may be necessary to optimally treat selected gram-negative bacteria (eg, P. aeruginosa) in patients with febrile neutropenia.
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Affiliation(s)
- Gary E Stein
- Department of Medicine, Michigan State University, East Lansing, USA.
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Antibiotic therapy in hematological neutropenic patients: what is the news? Leuk Suppl 2012; 1:S20-1. [PMID: 27175236 DOI: 10.1038/leusup.2012.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Bacterial infection is a very common complication in hematological neutropenic patients whose treatment is extremely challenging for several reasons. First, they are frequently caused by resistant pathogens (multidrug resistant (MDR)), and this may limit the availability of effective therapeutic weapons. Second, these patients often present peculiar pathophysiological conditions that may alter the pharmacokinetic behavior of antimicrobials, and this may explain the need for a new administration schedule and new dosing regimens of antibiotics in this setting. In an era in which there are only few new therapeutic weapons for the treatment of MDR bacterial infections, while advocating for new drugs, what could be effectively done nowadays is to increase the knowledge on appropriateness of the use of currently available drugs to improve clinical outcome and to preserve their activity.
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