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Le J, Bradley JS. Optimizing Antibiotic Drug Therapy in Pediatrics: Current State and Future Needs. J Clin Pharmacol 2019; 58 Suppl 10:S108-S122. [PMID: 30248202 DOI: 10.1002/jcph.1128] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/01/2018] [Indexed: 12/19/2022]
Abstract
The selection of the right antibiotic and right dose necessitates clinicians understand the contribution of pharmacokinetic variability stemming from age-related physiologic maturation and the pharmacodynamics to optimize drug exposure for clinical response. The complexity of selecting the right dose arises from the multiplicity of pediatric age groups, from premature neonates to adolescents. Body size and age (which relate to organ function) must be incorporated to optimize antibiotic dosing in this vulnerable population. In the effort to optimize and individualize drug dosing regimens, clinical pharmacometrics that incorporate population-based pharmacokinetic modeling, Bayesian estimation, and Monte Carlo simulations are utilized as a quantitative approach to understanding and predicting the pharmacology and clinical and microbiologic efficacy of antibiotics. In addition, opportunistic study designs and alternative blood sampling strategies can serve as practical approaches to ensure successful conduct of pediatric studies. This review article examines relevant literature on optimization of antibiotic pharmacotherapy in pediatric populations published within the last decade. Specific pediatric antibiotic data, including beta-lactam antibiotics, aminoglycosides, and vancomycin, are critically evaluated.
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Affiliation(s)
- Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, La Jolla, CA, USA
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA, USA.,Rady Children's Hospital San Diego, San Diego, CA, USA
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Abd-Elfattah R, Elhdad AM, Khames A, Abdelrahim ME, Shouman SA. Efficacy and toxicity of once versus twice daily regimens of amikacin in febrile neutropenic pediatric cancer patients. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2017. [DOI: 10.1016/j.bjbas.2017.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Stark D, Rosenberg AR, Johnston D, Knight K, Caperon L, Uleryk E, Frazier AL, Sung L. Patient-Reported Measures of Hearing Loss and Tinnitus in Pediatric Cancer and Hematopoietic Stem Cell Transplantation: A Systematic Review. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2016; 59:1247-1252. [PMID: 27603148 PMCID: PMC5962920 DOI: 10.1044/2016_jslhr-h-15-0363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 01/04/2016] [Indexed: 05/15/2023]
Abstract
PURPOSE We identified studies that described use of any patient-reported outcome scale for hearing loss or tinnitus among children and adolescents and young adults (AYAs) with cancer or hematopoietic stem cell transplantation (HSCT) recipients. METHOD In this systematic review, we performed electronic searches of OvidSP MEDLINE, EMBASE, and PsycINFO to August 2015. We included studies if they used any patient-reported scale of hearing loss or tinnitus among children and AYAs with cancer or HSCT recipients. Only English language publications were included. Two reviewers identified studies and abstracted data. RESULTS There were 953 studies screened; 6 met eligibility criteria. All studies administered hearing patient-reported outcomes only once, after therapy completion. None of the studies described the psychometric properties of the hearing-specific component. Three instruments (among 6 studies) were used: Health Utilities Index (Barr et al., 2000; Fu et al., 2006; Kennedy et al., 2014), Hearing Measurement Scales (Einar-Jon et al., 2011; Einarsson et al., 2011), and the Tinnitus Questionnaire for Auditory Brainstem Implant (Soussi & Otto, 1994). All had limitations, precluding routine use for hearing assessment in this population. CONCLUSIONS We identified few studies that included hearing patient-reported measures for children and AYA cancer and HSCT patients. None are ideal to take forward into future studies. Future work should focus on the creation of a new psychometrically sound instrument for hearing outcomes in this population.
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Affiliation(s)
- Daniel Stark
- Section of Oncology and Cancer Research, Leeds Institute of Molecular Medicine, University of Leeds, United Kingdom
| | | | - Donna Johnston
- Division of Paediatric Haematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Kristin Knight
- Pediatric Audiology, Oregon Health and Science University, Portland
| | - Lizzie Caperon
- Scholarly Communications and Researcher Skills, University of Leeds, United Kingdom
| | | | | | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Salehifar E, Rafati MR. Extended-Interval Dosing of Aminoglycosides in Pediatrics: A Narrative Review. JOURNAL OF PEDIATRICS REVIEW 2015. [DOI: 10.17795/jpr-2652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Dose derivation of once-daily dosing guidelines for gentamicin in critically ill pediatric patients. Ther Drug Monit 2015; 36:288-94. [PMID: 24695354 DOI: 10.1097/ftd.0000000000000016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES To determine dose and eligibility criteria for once-daily dosing (ODD) of gentamicin in critically ill pediatric patients. METHODS Retrospective chart review of patients admitted to the Pediatric Intensive Care Unit or Cardiac Critical Care Unit at The Hospital for Sick Children (SickKids) who received traditionally dosed intravenous (IV) gentamicin (January 2008 to June 2010). Statistically significant patient characteristics associated with gentamicin pharmacokinetic (PK) parameters were determined by multiple linear regression. Binary partitioning was used to set critical values for these characteristics to derive dose for ODD of gentamicin. Feasibility of implementing ODD of gentamicin in critically ill children was assessed using individualized PK parameters to simulate area under the concentration-time curves and drug-free intervals while targeting a maximum concentration (C(max)) of 16-20 mg/L. Eligibility criteria were determined by patient characteristics that had a statistically significant impact on gentamicin PK. RESULTS Volume of distribution (V(d)) and elimination rate constant (k(e)) were calculated for 140 patients. Weight and admission unit were significantly associated with weight-normalized V(d) (Vd/kg), whereas age and serum creatinine (SCr) were significantly associated with k(e). Weight <5 kg and SCr ≥20% over age-specific upper normal limit before gentamicin initiation were associated with prolonged gentamicin elimination. Gentamicin 6 mg/kg IV every 24 hours, the dose at which the highest percentage of patients achieved C(max), area under the curve, and drug-free interval within target ranges simultaneously, was selected as the proposed ODD regimen. CONCLUSIONS A regimen of gentamicin 6 mg/kg IV every 24 hours for Pediatric Intensive Care Unit/Cardiac Critical Care Unit patients at SickKids weighing ≥5 kg with SCr <20% above age-specific upper normal limit before initiation of gentamicin is proposed.
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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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Mareville J, Gay J, Cliquennois E, Herbaux C, Pasquier F, Allorge D, Blondiaux N, Berthon C, Alfandari S. Therapeutic drug monitoring of aminoglycosides in acute myeloid leukaemia patients. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 2012; 44:398-401. [PMID: 22235869 DOI: 10.3109/00365548.2011.645868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
International guidelines limit the use of aminoglycosides in febrile neutropenia to severe situations. We retrospectively reviewed the use of aminoglycosides in adult acute myeloid leukaemia patients admitted in 2009. Our guidelines include precise indications (severe sepsis, shock, drug resistance), dosing regimens (once-daily 20 mg/kg/day amikacin, 5 mg/kg/day gentamicin), durations of treatment, drug monitoring timing, and target C(max) concentrations (40 mg/l amikacin, 20 mg/l gentamicin). Thirty-one patients received 46 aminoglycoside courses: 31 amikacin and 15 gentamicin. The mean prescribed dosage was 19 ± 2.8 mg/kg/day for amikacin and 4.7 ± 0.9 mg/kg/day for gentamicin. The mean duration of use was 2.9 days for both drugs. The mean C(max) for amikacin was 47 ± 13 mg/l and for gentamicin was 13.6 ± 7.5 mg/l. In compliant regimens, all amikacin patients and a third of gentamicin patients had adequate C(max). Among 23 isolated pathogens, 65.5% were susceptible to both drugs and 11.5% to amikacin only. This vindicates the 20 mg/kg/day amikacin dosage and suggests a need to increase the gentamicin dosage.
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Mavros MN, Polyzos KA, Rafailidis PI, Falagas ME. Once versus multiple daily dosing of aminoglycosides for patients with febrile neutropenia: a systematic review and meta-analysis. J Antimicrob Chemother 2010; 66:251-9. [DOI: 10.1093/jac/dkq451] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Inparajah M, Wong C, Sibbald C, Boodhan S, Atenafu EG, Naqvi A, Dupuis LL. Once-Daily Gentamicin Dosing in Children with Febrile Neutropenia Resulting from Antineoplastic Therapy. Pharmacotherapy 2010; 30:43-51. [DOI: 10.1592/phco.30.1.43] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lortholary O, Lefort A, Tod M, Chomat AM, Darras-Joly C, Cordonnier C. Pharmacodynamics and pharmacokinetics of antibacterial drugs in the management of febrile neutropenia. THE LANCET. INFECTIOUS DISEASES 2008; 8:612-20. [DOI: 10.1016/s1473-3099(08)70228-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
Amikacin is an aminoglycoside commonly used to provide empirical double gram-negative treatment for febrile neutropenia and other suspected infections. Strategies of extended-interval and conventional dosing have been utilized extensively in the general medical population; however, data are lacking to support a dosing strategy in the hematology/oncology population. To evaluate amikacin-associated nephrotoxicity in an adult hematology/oncology population, a prospective, randomized, open-label trial was conducted at a university-affiliated medical center. Forty patients with a diagnosis consistent with a hematologic/oncologic disorder that required treatment with an aminoglycoside were randomized to either conventional or extended-interval amikacin. The occurrence of nephrotoxicity by means of an increase in serum creatinine and evaluation of efficacy via amikacin serum concentrations with respective pathogens were assessed. The occurrence of nephrotoxicity was similar between the conventional and extended-interval groups, at 10% and 5%, respectively (P = 1.00). Six patients in the conventional group had a positive culture, compared with none in the extended-interval group (P = 0.002). The occurrence of nephrotoxicity was similar between the two dosing regimens, but the distribution of risk factors was variable between the two groups. Efficacy could not be assessed.
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Drgona L, Paul M, Bucaneve G, Calandra T, Menichetti F. The need for aminoglycosides in combination with β-lactams for high-risk, febrile neutropaenic patients with leukaemia. EJC Suppl 2007. [DOI: 10.1016/j.ejcsup.2007.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Lam W, Tjon J, Seto W, Dekker A, Wong C, Atenafu E, Bitnun A, Waters V, Yau Y, Solomon M, Ratjen F. Pharmacokinetic modelling of a once-daily dosing regimen for intravenous tobramycin in paediatric cystic fibrosis patients. J Antimicrob Chemother 2007; 59:1135-40. [PMID: 17446242 DOI: 10.1093/jac/dkm097] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study was designed to determine an optimal dose range for the once-daily dosing (ODD) of tobramycin in the treatment of an acute pulmonary exacerbation in paediatric cystic fibrosis (CF) patients. In addition, we aimed to assess whether certain patient characteristics affect tobramycin pharmacokinetics and, therefore, dosing. METHODS Patient characteristics and pharmacokinetic parameters of patients receiving tobramycin three times daily from 1 January 1992 to 31 October 2005 were analysed using univariate analysis and multiple linear regression to determine statistically significant relationships and to derive dosing models. The binary partitioning method was used to derive critical values to determine stratification within the chosen dosing model. RESULTS Using multiple linear regression, age and sex were significantly associated with the volume of distribution divided by the body weight (V/kg). By the binary partitioning method, the critical value for age was 13.75 years. CONCLUSIONS Age and sex were used to derive an ODD regimen for tobramycin in paediatric CF. Using a target peak concentration range of 25-35 mg/L, the initial dose for female CF patients at least 14 years of age was calculated to be 7 mg/kg/day given intravenously as a single daily dose. All other CF patients would receive an initial dose of 9 mg/kg/day given intravenously as a single daily dose. These dosing guidelines will require prospective evaluation for safety and efficacy.
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Affiliation(s)
- Wallace Lam
- Department of Pharmacy Services, Princess Margaret Hospital, University Health Network, Toronto, Ontario, Canada
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Rengelshausen J, Beedgen B, Tsamouranis K, Mikus G, Walter-Sack I, Haefeli WE, Linderkamp O. Pharmacokinetics of a netilmicin loading dose on the first postnatal day in preterm neonates with very w gestational age. Eur J Clin Pharmacol 2006; 62:773-7. [PMID: 16865390 DOI: 10.1007/s00228-006-0153-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Accepted: 04/28/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Pharmacokinetic parameters are important for dose adjustment of aminoglycosides, but they are highly variable in neonates. In this study the pharmacokinetics of a netilmicin loading dose was investigated on the first postnatal day in preterm neonates with very low gestational age (GA). METHODS In an open prospective study, 20 neonates with GA between 22.9 and 32.0 weeks and suspected postnatal bacterial infection received an intravenous loading dose of 5 mg/kg netilmicin over 1 h during the first postnatal day. Netilmicin serum concentrations were determined by an enzyme multiplied immunoassay. RESULTS The systemic clearance of netilmicin normalized to body weight (BW) was not significantly different in three GA subgroups (0.59+/- 0.02 ml/min/kg for GA <24 weeks, 0.72+/-0.14 ml/min/kg for GA 24-27 weeks, and 0.62+/-0.19 ml/min/kg for GA 27-32 weeks, P=0.123). Similar results were also obtained for serum elimination half-time and for the distribution volume normalized to BW. Multiple regression analysis showed that systemic clearance and volume of distribution (both not normalized to BW) significantly correlated with BW (P<0.0001) but not with GA. In the entire group, 20% of peak concentrations were below the target of 6 mg/l, and 63% of trough concentrations were above the target of 2 mg/l. CONCLUSION In neonates with very low GA, the pharmacokinetic parameters of netilmicin determined after an intravenous loading dose were not dependent on GA when normalized to BW. A number of neonates did not reach targeted peak and trough netilmicin serum concentrations, suggesting that a higher loading dose and a prolonged dosing interval might enhance the effectiveness and safety of netilmicin in preterm neonates immediately after birth.
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Affiliation(s)
- Jens Rengelshausen
- Department of Internal Medicine VI, Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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Punnett A, Bliss B, Dupuis LL, Abdolell M, Doyle J, Sung L. Ototoxicity following pediatric hematopoietic stem cell transplantation: a prospective cohort study. Pediatr Blood Cancer 2004; 42:598-603. [PMID: 15127414 DOI: 10.1002/pbc.20036] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Our objectives were to describe the frequency and determine risk factors for hearing deterioration following pediatric stem cell transplantation (SCT). METHODS In this prospective cohort study, we performed pure tone audiometry and measured otoacoustic emissions (OAE) prior to and following SCT. Worse hearing was considered deterioration in either audiometry or OAE. RESULTS Between October 2000 and November 2002, 45 informative audiometry or OAE results were obtained. Hearing deteriorated following SCT in 20/45 (44%) of these children. Those with worse hearing following SCT were more likely to have neuroblastoma (odds ratio [OR] 16.0 [95% CI 1.8, 143.2; P = 0.003]), receive carboplatin conditioning (OR 7.7 [95% CI 1.4, 41.9; P = 0.01]), have abnormal baseline hearing (OR 5.1 [95% CI 1.3, 19.5; P = 0.02]), and have higher baseline serum creatinine (OR for every increase of 5 micromol/L of serum creatinine of 1.5 [95% CI 1.03, 2.1; P = 0.03]). CONCLUSION Many children who undergo SCT will have deterioration in hearing following SCT. A high-risk group of children can be delineated who may benefit from more intensive audiological monitoring following SCT.
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Affiliation(s)
- Angela Punnett
- Department of Pediatrics, University of Toronto, Ontario, Canada
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Dupuis LL, Sung L, Taylor T, Abdolell M, Allen U, Doyle J, Taddio A. Tobramycin Pharmacokinetics in Children with Febrile Neutropenia Undergoing Stem Cell Transplantation: Once-Daily versus Thrice-Daily Administration. Pharmacotherapy 2004; 24:564-73. [PMID: 15162890 DOI: 10.1592/phco.24.6.564.34743] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To describe the pharmacokinetic disposition of tobramycin in children undergoing stem cell transplantation (SCT) after intravenous administration either every 24 hours or every 8 hours, and to use this information to create initial dosing guidelines for administration every 24 hours in this patient population. DESIGN Pharmacokinetic analysis of a randomized controlled trial. SETTING The Hospital for Sick Children, Toronto, Ontario, Canada. PATIENTS Sixty children (< 18 yrs) with febrile neutropenia undergoing stem cell transplantation. INTERVENTION Patients were randomized to receive intravenous tobramycin either every 24 hours (29 patients) or every 8 hours (31 patients). Initially, they received either 2.5 mg/kg/dose every 8 hours or weight-based doses by age group (< 5 yrs, 9 mg/kg/dose; 5 to < 12 yrs, 8 mg/kg/dose; > or = 12 yrs, 7 mg/kg/dose) every 24 hours. MEASUREMENTS AND MAIN RESULTS Serum tobramycin concentrations were obtained at 2 and 8 hours after the first dose. Initial guidelines for dosing every 24 hours were derived using the parameters from all patients to achieve a maximum serum concentration (Cmax) of 20-22.5 mg/L and a drug-free interval (time during dosing interval when the tobramycin concentration was < 1 mg/L) of at least 4 hours. After the first tobramycin dose, the elimination rate constant (kel) and volume of distribution (Vd) observed in the every-8-hour group (23 patients) were 0.34 +/- 0.09 hours(-1) and 0.48 +/- 0.21 L/kg, respectively. The kel and Vd in the every-24-hour group (22 patients) were 0.43 +/- 0.12 hr(-1) and 0.43 +/- 0.26 L/kg, respectively. Tobramycin Vd varied with age. Initial doses of tobramycin every 24 hours recommended to achieve the target parameters are 10 mg/kg/dose for patients aged 6 months to less than 9 years, 8 mg/kg/dose for those aged 9 to less than 12 years, and 6 mg/kg/dose for those aged 12 years or older. CONCLUSION Children undergoing SCT who receive tobramycin every 24 hours should receive an initial dose based on age. Further validation of the proposed dosing guidelines is required.
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Affiliation(s)
- L Lee Dupuis
- Department of Pharmacy, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
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