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Ngougni Pokem P, Vanneste D, Schouwenburg S, Abdulla A, Gijsen M, Dhont E, Van der Linden D, Spriet I, De Cock P, Koch B, Van Bambeke F, Wijnant GJ. Dose optimization of β-lactam antibiotics in children: from population pharmacokinetics to individualized therapy. Expert Opin Drug Metab Toxicol 2024:1-18. [PMID: 39078238 DOI: 10.1080/17425255.2024.2385403] [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: 04/16/2024] [Revised: 06/21/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION β-Lactams are the most widely used antibiotics in children. Their optimal dosing is essential to maximize their efficacy, while minimizing the risk for toxicity and the further emergence of antimicrobial resistance. However, most β-lactams were developed and licensed long before regulatory changes mandated pharmacokinetic studies in children. As a result, pediatric dosing practices are poorly harmonized and off-label use remains common today. AREAS COVERED β-Lactam pharmacokinetics and dose optimization strategies in pediatrics, including fixed dose regimens, therapeutic drug monitoring, and model-informed precision dosing are reviewed. EXPERT OPINION/COMMENTARY Standard pediatric doses can result in subtherapeutic exposure and non-target attainment for specific patient subpopulations (neonates, critically ill children, e.g.). Such patients could benefit greatly from more individualized approaches to dose optimization, beyond a relatively simple dose adaptation based on weight, age, or renal function. In this context, Therapeutic Drug Monitoring (TDM) and Model-Informed Precision Dosing (MIPD) emerge as particularly promising avenues. Obstacles to their implementation include the lack of strong evidence of clinical benefit due to the paucity of randomized clinical trials, of standardized assays for monitoring concentrations, or of adequate markers for renal function. The development of precision medicine tools is urgently needed to individualize therapy in vulnerable pediatric subpopulations.
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Affiliation(s)
- Perrin Ngougni Pokem
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Department of Microbiology, Cliniques Universitaires Saint-Luc - Université catholique de Louvain, Brussels, Belgium
| | - Dorian Vanneste
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Stef Schouwenburg
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Evelyn Dhont
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Dimitri Van der Linden
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
- Pediatric Infectious Diseases, Service of Specialized Pediatrics, Department of Pediatrics, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Pieter De Cock
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Birgit Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Françoise Van Bambeke
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Gert-Jan Wijnant
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Laboratory of Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Xie M, Jiang M, Qiu H, Rong L, Kong L. Optimization of Voriconazole Dosing Regimens Against Aspergillus Species and Candida Species in Pediatric Patients After Hematopoietic Cell Transplantation: A Theoretical Study Based on Pharmacokinetic/Pharmacodynamic Analysis. J Clin Pharmacol 2023; 63:993-1001. [PMID: 37083934 DOI: 10.1002/jcph.2254] [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: 01/03/2023] [Accepted: 04/17/2023] [Indexed: 04/22/2023]
Abstract
This study aimed to optimize the dosing regimens of voriconazole (VRC) for pediatric patients after hematopoietic cell transplantation with different cytochrome P450 (CYP) 2C19 phenotypes and body weights, based on pharmacokinetic (PK)/pharmacodynamic (PD) analysis. The PK parameters of VRC were derived from previous literature. Combined with key factors affecting VRC, patients were categorized into 9 subgroups based on different CYP2C19 phenotypes (poor metabolizer/intermediate metabolizer, normal metabolizer, and rapid metabolizer/ultrarapid metabolizer) and typical body weights (15, 40, and 65 kg). Monte Carlo simulation was used to investigate dosing regimens for different groups. The area under the 24-hour free drug concentration-time curve to the minimum inhibitory concentration (MIC) > 25 was used as the target value for effective treatment. The probability of target achievement and the cumulative fraction of response were determined on the basis of the assumed MICs and MICs distribution frequency of Aspergillus species and Candida species. When the MIC was ≤1 mg/L, 4 mg/kg every 12 hours was sufficient for optimal effects in groups 1-3 and groups 5 and 6; however, 6 mg/kg every 12 hours was required for group 4, and 8 mg/kg every 12 hours was required for groups 7-9. In empirical treatment, lower (2-6 mg/kg every 12 hours) and higher (6-12 mg/kg every 12 hours) dosing regimens were recommended for Candida spp. and Aspergillus spp., respectively. Our findings will assist in selecting appropriate dosing regimens of VRC for pediatric patients after hematopoietic cell transplantation with different CYP2C19 phenotypes and body weights. Clinically, it is better to continuously adjust the dosing on the basis of the therapeutic drug monitoring.
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Affiliation(s)
- Mengyuan Xie
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Manxue Jiang
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Hongyu Qiu
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Li Rong
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
| | - Lingti Kong
- Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
- School of Pharmacy, Bengbu Medical College, Bengbu, China
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Velarde-Salcedo R, Pérez-González LF, Rodríguez-Báez AS, Arriaga-García FJ, Milán-Segovia RDC, Romano-Moreno S, Medellín-Garibay SE. Model-informed precision dosing of antimicrobial drugs in pediatrics: experiences from a pilot scale program. Eur J Pediatr 2023; 182:4143-4152. [PMID: 37436522 DOI: 10.1007/s00431-023-05103-z] [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: 05/16/2023] [Revised: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
Antibiotics are among the most utilized drugs in pediatrics. Nonetheless, there is a lack in pharmacokinetics information for this population, and dosing criteria may vary between healthcare centers. Physiological variability associated with maturation in pediatrics makes it challenging to reach a consensus on adequate dosing, which is further accentuated in more vulnerable groups, such as critically ill or oncology patients. Model-informed precision dosing is a useful practice that allows dose optimization and attainment of antibiotic-specific pharmacokinetic/pharmacodynamic targets. The aim of this study was to evaluate the needs of model-informed precision dosing of antibiotics in a pediatrics unit, at a pilot scale. Pediatric patients under antibiotic treatment were monitored with either a pharmacokinetic/pharmacodynamic optimized sampling scheme or through opportunistic sampling. Clindamycin, fluconazole, linezolid, meropenem, metronidazole, piperacillin, and vancomycin plasma concentrations were quantified through a liquid chromatography coupled to mass spectrometry method. Pharmacokinetic parameters were estimated using a Bayesian approach to verify pharmacokinetic/pharmacodynamic target attainment. A total of 23 pediatric patients aged 2 to 16 years were included, and 43 dosing regimens were evaluated; 27 (63%) of them required adjustments as follows: 14 patients were underdosed, 4 were overdosed, and 9 patients needed infusion rate adjustments. Infusion rate adjustments were mostly recommended for piperacillin and meropenem; daily doses were augmented for vancomycin and metronidazole, meanwhile linezolid was adjusted for under- and overdosing. Clindamycin and fluconazole regimens were not adjusted at all. Conclusion: Results showcase a lack of antibiotic pharmacokinetic/pharmacodynamic target attainment (particularly for linezolid, vancomycin, meropenem, and piperacillin), and the need for model-informed precision dosing in pediatrics. This study provides pharmacokinetic evidence which can further improve antibiotic dosing practices. What is Known: • Model-informed precision dosing is performed in pediatrics to optimize the treatment of antimicrobial drugs such as vancomycin and aminoglycosides, while its usefulness is debated for other groups (beta-lactams, macrolides, etc.). What is New: • Vulnerable pediatric subpopulations, such as critically ill or oncology patients, can benefit the most from model-informed precision dosing of antibiotics. • Model-informed precision dosing of linezolid, meropenem, piperacillin, and vancomycin is particularly useful in pediatrics, and further research may improve dosing practices altogether.
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Affiliation(s)
- Rodrigo Velarde-Salcedo
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, San Luis Potosí, S.L.P., México
| | | | | | | | | | - Silvia Romano-Moreno
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, San Luis Potosí, S.L.P., México
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Hong LT, Downes KJ, FakhriRavari A, Abdul-Mutakabbir JC, Kuti JL, Jorgensen S, Young DC, Alshaer MH, Bassetti M, Bonomo RA, Gilchrist M, Jang SM, Lodise T, Roberts JA, Tängdén T, Zuppa A, Scheetz MH. International consensus recommendations for the use of prolonged-infusion beta-lactam antibiotics: Endorsed by the American College of Clinical Pharmacy, British Society for Antimicrobial Chemotherapy, Cystic Fibrosis Foundation, European Society of Clinical Microbiology and Infectious Diseases, Infectious Diseases Society of America, Society of Critical Care Medicine, and Society of Infectious Diseases Pharmacists. Pharmacotherapy 2023; 43:740-777. [PMID: 37615245 DOI: 10.1002/phar.2842] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/15/2022] [Accepted: 12/26/2022] [Indexed: 08/25/2023]
Abstract
Intravenous β-lactam antibiotics remain a cornerstone in the management of bacterial infections due to their broad spectrum of activity and excellent tolerability. β-lactams are well established to display time-dependent bactericidal activity, where reductions in bacterial burden are directly associated with the time that free drug concentrations remain above the minimum inhibitory concentration (MIC) of the pathogen during the dosing interval. In an effort to take advantage of these bactericidal characteristics, prolonged (extended and continuous) infusions (PIs) can be applied during the administration of intravenous β-lactams to increase time above the MIC. PI dosing regimens have been implemented worldwide, but implementation is inconsistent. We report consensus therapeutic recommendations for the use of PI β-lactams developed by an expert international panel with representation from clinical pharmacy and medicine. This consensus guideline provides recommendations regarding pharmacokinetic and pharmacodynamic targets, therapeutic drug-monitoring considerations, and the use of PI β-lactam therapy in the following patient populations: severely ill and nonseverely ill adult patients, pediatric patients, and obese patients. These recommendations provide the first consensus guidance for the use of β-lactam therapy administered as PIs and have been reviewed and endorsed by the American College of Clinical Pharmacy (ACCP), the British Society for Antimicrobial Chemotherapy (BSAC), the Cystic Fibrosis Foundation (CFF), the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), the Infectious Diseases Society of America (IDSA), the Society of Critical Care Medicine (SCCM), and the Society of Infectious Diseases Pharmacists (SIDP).
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Affiliation(s)
- Lisa T Hong
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Kevin J Downes
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | - Jacinda C Abdul-Mutakabbir
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
- Divisions of Clinical Pharmacy and Black Diaspora and African American Studies, University of California San Diego, La Jolla, California, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | | | - David C Young
- University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | | | | | - Robert A Bonomo
- Cleveland Veteran Affairs Medical Center, Cleveland, Ohio, USA
- Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Case Western Reserve University, Cleveland, Ohio, USA
| | - Mark Gilchrist
- Imperial College Healthcare National Health Services Trust, London, UK
| | - Soo Min Jang
- Loma Linda University School of Pharmacy, Loma Linda, California, USA
| | - Thomas Lodise
- Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Center for Clinical Research, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Thomas Tängdén
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marc H Scheetz
- College of Pharmacy, Pharmacometric Center of Excellence, Midwestern University, Downers Grove, Illinois, USA
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
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Amano E, Tanaka R, Ono H, Tatsuta R, Hashimoto T, Hiramatsu K, Itoh H. Association of Vancomycin Trough Concentration and Clearance With Febrile Neutropenia in Pediatric Patients. Ther Drug Monit 2022; 44:543-551. [PMID: 35821590 DOI: 10.1097/ftd.0000000000000978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Febrile neutropenia promotes renal drug excretion. Adult and pediatric patients with febrile neutropenia exhibit a lower vancomycin concentration/dose (relative to bodyweight) ratio than those with other infections. In pediatric patients, renal function relative to bodyweight varies depending on age, and vancomycin clearance is age dependent. This study aimed to analyze the effects of febrile neutropenia on the pharmacokinetics of vancomycin in age-stratified pediatric patients. METHODS This retrospective, single-center, observational cohort study analyzed 112 hospitalized pediatric patients who met the selection criteria and intravenously received vancomycin at the Department of Pediatrics of the Oita University Hospital between April 2011 and October 2019. RESULTS The febrile neutropenia (n = 46) cohort exhibited a significantly higher estimated glomerular filtration rate than the nonfebrile neutropenia (n = 66) cohort. Compared with those in the nonfebrile neutropenia cohort, the daily vancomycin dose relative to bodyweight and vancomycin clearance were significantly higher, and the vancomycin trough concentration and vancomycin concentration/dose ratio were significantly lower in the febrile neutropenia cohort. In the age groups of 1-6 and 7-12 years, compared with those in the nonfebrile neutropenia cohort, the vancomycin concentration/dose ratio was significantly lower, and vancomycin clearance was significantly higher in the febrile neutropenia cohort. Univariate and multivariate analyses identified febrile neutropenia as the independent factor influencing vancomycin concentration/dose ratio and clearance only in pediatric patients aged 1-6 years. CONCLUSIONS Increased initial dosage and therapeutic drug monitoring-guided dose optimization are critical for the therapeutic efficacy of vancomycin in pediatric patients with febrile neutropenia, especially in those aged 1-6 years.
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Affiliation(s)
- Erino Amano
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Hiroyuki Ono
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Ryosuke Tatsuta
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
| | - Takehiro Hashimoto
- Department of Respiratory Medicine and Infectious Diseases, Oita University, Faculty of Medicine, Yufu, Oita, Japan
| | - Kazufumi Hiramatsu
- Department of Respiratory Medicine and Infectious Diseases, Oita University, Faculty of Medicine, Yufu, Oita, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Yufu, Oita, Japan; and
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Butragueño-Laiseca L, Marco-Ariño N, Troconiz IF, Grau S, Campillo N, García X, Padilla B, Fernández SN, Slöcker M, Santiago MJ. Population pharmacokinetics of piperacillin in critically ill children including those undergoing continuous kidney replacement therapy. Clin Microbiol Infect 2022; 28:1287.e9-1287.e15. [PMID: 35390523 DOI: 10.1016/j.cmi.2022.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/09/2022] [Accepted: 03/22/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Despite that piperacillin-tazobactam combination is commonly used in critically ill children, increasing evidence suggests that the current dosing schedules are not optimal for these patients. The aim of this work is to develop a population pharmacokinetic (PK) model for piperacillin to evaluate the efficacy of standard dosing in children with and without kidney replacement therapy (CKRT), and to propose alternative dosing schemes maximizing target attainment. METHODS 429 piperacillin concentrations measured in different matrices, obtained from 32 critically ill children (19 without CKRT, 13 with CKRT) receiving 100 mg/kg of piperacillin/tazobactam every 8 hours (increased to 12h after the 4th dose) were modelled simultaneously using the population approach with NONMEM 7.4. The percentage of patients with 90% fT>MIC and target attainment (percentage of dosing interval above MIC) were estimated for different intermittent and continuous infusions in the studied population. RESULTS Piperacillin PK was best described with a two-compartment model. Renal (CLR), nonrenal (CLM), and hemofilter (CLCKRT) clearances were found to be influenced by the glomerular filtration rate, height (CLR), weight (CLM) and filter surface (CLCKRT). Only 7 (37%) children without CKRT and 7 (54%) with CKRT achieved 90% fT >MIC with the current dosing schedule. Of the alternative regimens evaluated, a 24h continuous infusion of 200 mg/kg (CKRT) and 300 mg/kg (no CKRT) provided 100% fT >MIC(≤16mg/L) and target attainments ≥90% across all evaluated MICs. CONCLUSIONS In children with and without CKRT, standard dosing failed to provide an adequate systemic exposure, while prolonged and continuous infusions showed an improved efficacy.
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Affiliation(s)
- Laura Butragueño-Laiseca
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - Nicolás Marco-Ariño
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Iñaki F Troconiz
- Pharmacometrics & Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Santiago Grau
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona Barcelona, Spain
| | - Nuria Campillo
- Pharmacy Department, Hospital del Mar, Universitat Autònoma de Barcelona Barcelona, Spain
| | - Xandra García
- Pharmacy Department, Hospital General Universitario Gregorio Marañón
| | - Belén Padilla
- Clinical Microbiology Department, Hospital General Universitario Gregorio Marañón
| | - Sarah Nicole Fernández
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María Slöcker
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain
| | - María José Santiago
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Gregorio Marañón Health Research Institute (IISGM), Madrid, Spain; Pediatrics Department, Universidad Complutense de Madrid, Spain; Maternal and Child Health and Development Research Network (REDSAMID), Institute of Health Carlos III, Madrid, Spain.
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Estimation of cefepime, piperacillin, and tazobactam clearance with iohexol-based glomerular filtration rate in paediatric patients. Eur J Clin Pharmacol 2022; 78:989-1001. [PMID: 35275224 DOI: 10.1007/s00228-022-03307-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/04/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Estimated glomerular filtration rate (eGFR) equations reflect kidney function imprecisely. We aimed to describe whether iohexol-based GFR or eGFRs predict clearance of cefepime, piperacillin, and tazobactam in pharmacokinetic (PK) models in this population and its clinical significance. METHODS Hospitalized patients (0.5-25 years) with haemato-oncological disease and infection receiving cefepime or piperacillin/tazobactam were included. PK samples were collected at a steady state concomitantly with samples for iohexol-based GFR. PK models were developed in NONMEM. Weight, postmenstrual age, iohexol-based GFR, different eGFR equations (Schwartz updated, Lund-Malmö revised, CKD-EPI, Bouvet, Schwartz cystatin C-based) were tested as covariates. Probabilities of neurotoxic/therapeutic concentrations were assessed by simulations. RESULTS Fifteen patients receiving cefepime and 17 piperacillin/tazobactam were included (median (range) age 16.2 (1.9-26.0) and 10.5 (0.8-25.6) years, iohexol-based GFR 102 (68-140) and 116 (74-137) mL/min/1.73 m2, respectively). Two-compartment model provided the best fit for all drugs. Weight was covariate for central and peripheral compartment, clearance and intercompartmental clearance (only tazobactam), and postmenstrual age for clearance (excluding cefepime). Iohexol-based GFR was the best predictor of clearance. The model of cefepime without vs with iohexol-based GFR underestimated the probability of neurotoxic concentrations (28.3-28.6% vs 52.1-69.3%) and overestimated the probability of therapeutic concentrations (> 90% vs 81.9-87.1%) in the case of iohexol-based GFR 70-80 and 130-140 mL/min/1.73 m2, respectively. CONCLUSION Iohexol-based GFR can predict better than eGFRs the clearance of cefepime, piperacillin, and tazobactam in children and young adults with haemato-oncological disease and infection, warranting further investigation as an indicator of renal function to improve targeting of therapeutic window. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION EudraCT 2015-000,631-32, EudraCT 2016-003,374-40 (24.10.2016).
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Maarbjerg SF, Thorsted A, Friberg LE, Nielsen EI, Wang M, Schrøder H, Albertsen BK. Continuous infusion of piperacillin-tazobactam significantly improves target attainment in children with cancer and fever. Cancer Rep (Hoboken) 2021; 5:e1585. [PMID: 34796702 PMCID: PMC9575485 DOI: 10.1002/cnr2.1585] [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: 06/30/2021] [Revised: 09/02/2021] [Accepted: 10/25/2021] [Indexed: 11/07/2022] Open
Abstract
Background Children with febrile neutropenia commonly exhibit alterations of pharmacokinetic (PK) parameters, leading to decreased β‐lactam concentrations. Aims This study evaluated piperacillin PK and probability of target attainment (PTA) with continuous infusion of piperacillin‐tazobactam, in order to optimize the dosing regimen. Methods This prospective PK study included children with cancer, aged 1–17 years, who were treated with piperacillin‐tazobactam for suspected or verified infection. A piperacillin‐tazobactam loading dose (100 mg/kg) was administered followed by continuous infusion (300 mg/kg/day). The unbound fraction of piperacillin was quantified by high‐performance liquid chromatography and PK were described using population PK modeling. PK data was used to update and extend a previous PK model built on data following intermittent administration. Monte Carlo simulations were performed to assess PTA for targets of 100% time above the minimum inhibitory concentration (100% fT > MIC) and 50% fT > 4xMIC. Results We included 68 fever episodes among 38 children with a median (IQR) age of 6.5 years and body weight of 27.4 kg (15.1–54.0). A three‐compartment model adequately described the concentration‐time data. Median (95% confidence interval) estimates for clearance and piperacillin concentration at steady state were 14.2 L/h/70 kg (13.0; 15.3) and 47.6 mg/L (17.2; 129.5), respectively. Body weight or lean body weight was significantly associated with the PK parameters, and body weight was integrated in the final PK model. Based on piperacillin exposure, continuous infusion was the only dosing regimen to achieve optimal PTA for the P. aeruginosa breakpoint (16 mg/L) with the target of 100% fT > MIC, and a daily dose of 300 mg/kg reached optimal PTA. The strict target of 50% fT > 4xMIC (64 mg/L) was not feasibly attained by any dosing regimen at recommended doses. Conclusion Unlike conventional piperacillin intermittent administration and extended infusion regimens, continuous infusion allows the target of 100% fT > MIC to be reached for children with febrile neutropenia.
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Affiliation(s)
- Sabine F Maarbjerg
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | - Mikala Wang
- Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Schrøder
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte K Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Shimamoto Y, Verstegen RHJ, Mizuno T, Schechter T, Allen U, Ito S. Population pharmacokinetics of vancomycin in paediatric patients with febrile neutropenia and augmented renal clearance: development of new dosing recommendations. J Antimicrob Chemother 2021; 76:2932-2940. [PMID: 34480578 DOI: 10.1093/jac/dkab302] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 07/23/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the influence of augmented renal clearance (ARC) on vancomycin clearance and provide dosage recommendations for paediatric patients with febrile neutropenia following HSCT. METHODS A population pharmacokinetic analysis was performed based on a two-compartment model structure using a non-linear mixed-effect modelling approach. Monte Carlo simulations were conducted as a target attainment analysis of AUC between 400 mg·h/L and 650 mg·h/L for MRSA at an MIC of 1 mg/L. RESULTS A total of 165 paediatric patients and 276 vancomycin serum concentrations were analysed in this study. Age, body weight, estimated glomerular filtration rate (eGFR) and fever (≥38.0°C) were identified as factors that significantly influenced vancomycin clearance. The median eGFR of the population was 143 mL/min/1.73 m2 and 34% of patients showed an eGFR ≥160 mL/min/1.73 m2, which may be classified as ARC. Our simulations showed that current dosing recommendations result in poor target attainment. In particular, children aged 6 months old to 6 years old with ARC require an initial vancomycin dose up to 35%-65% higher than the current dosing guidelines. CONCLUSIONS ARC is frequently observed in paediatric patients with post-HSCT febrile neutropenia, resulting in a significant increase in vancomycin clearance. We propose a vancomycin dosing strategy for children with febrile neutropenia following HSCT based on eGFR, age, weight and body temperature.
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Affiliation(s)
- Yuko Shimamoto
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ruud H J Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tal Schechter
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Hematology/Oncology/BMT, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Upton Allen
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Prolonged infusion of beta-lactam antibiotics for Gram-negative infections: rationale and evidence base. Curr Opin Infect Dis 2021; 33:501-510. [PMID: 33009140 DOI: 10.1097/qco.0000000000000681] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to discuss the rationale of and current evidence for prolonged beta-lactam infusion in the management of Gram-negative infections. RECENT FINDINGS Pharmacokinetic/pharmacodynamic (PK/PD) data from various in-vitro and in-vivo experimental studies conclusively support prolonged infusion over intermittent infusion in terms of achieving effective beta-lactam exposure for maximal bacterial killing. Superior PK/PD target attainment has been demonstrated with prolonged beta-lactam infusion in patient populations that are more likely to have less susceptible Gram-negative infections. These populations include critically ill patients, cystic fibrosis patients and patients with malignant diseases. The clinical impact of prolonged beta-lactam infusion is likely to be the greatest in these patient groups: critically ill patients with a high level of illness severity who are not receiving renal replacement therapy; patients with nonfermenting Gram-negative bacilli infection and patients with respiratory infection. Critically ill patients with augmented renal clearance may not achieve effective beta-lactam exposure even with the use of prolonged infusion. Maximizing the effectiveness of prolonged beta-lactam infusion via therapeutic drug monitoring is becoming a more common strategy in the management of critically ill patients with Gram-negative infection. SUMMARY Prolonged beta-lactam infusion may not benefit all patients but only for those who are critically ill and/or immunocompromised, who are also more likely to have less susceptible Gram-negative infections.
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