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Toy C, Stimes G, Moore M, Srivaths P, Arikan AA. Cefepime Dosing in a Critically Ill Neonate Receiving Continuous Renal Replacement Therapy With the Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM). J Pediatr Pharmacol Ther 2023; 28:167-171. [PMID: 37139247 PMCID: PMC10150901 DOI: 10.5863/1551-6776-28.2.167] [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: 01/06/2022] [Accepted: 04/22/2022] [Indexed: 05/05/2023]
Abstract
We report on a former 27-week gestational age infant who was placed on the Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM) at 4 months post-menstrual age while receiving cefepime treatment for an Enterobacter cloacae bacteremia and persistent peritonitis secondary to an infected peritoneal dialysis catheter. Using therapeutic drug monitoring while assessing the clearance of cefepime on continuous renal replacement therapy (CRRT), we were able to successfully treat this patient's infection while also minimizing the risk of side effects from this medication. Current literature supports dosing in adult patients on all modalities of CRRT with effluent flow rates of 20 to 25 mL/kg/hr; however, pharmacokinetic data on cefepime dosing in pediatric CRRT are scant. This case report describes the successful dosing strategy used for this patient while on various rates of continuous veno-venous hemodialysis with CARPEDIEM. Therapeutic drug monitoring of cefepime should be considered in critically ill pediatric patients on CARPEDIEM receiving CRRT.
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Affiliation(s)
- Cynthia Toy
- Department of Pharmacy Services (CT, GS, MM), Texas Children's Hospital, Houston, TX
| | - Grant Stimes
- Department of Pharmacy Services (CT, GS, MM), Texas Children's Hospital, Houston, TX
| | - Megan Moore
- Department of Pharmacy Services (CT, GS, MM), Texas Children's Hospital, Houston, TX
| | - Poyyapakkam Srivaths
- Department of Pediatrics, Renal Section (PS, AAA), Baylor College of Medicine, Houston, TX
| | - Ayse Akcan Arikan
- Department of Pediatrics, Renal Section (PS, AAA), Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Section of Critical Care Medicine (AAA), Baylor College of Medicine, Houston, TX
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2
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Pais GM, Chang J, Barreto EF, Stitt G, Downes KJ, Alshaer MH, Lesnicki E, Panchal V, Bruzzone M, Bumanglag AV, Burke SN, Scheetz MH. Clinical Pharmacokinetics and Pharmacodynamics of Cefepime. Clin Pharmacokinet 2022; 61:929-953. [PMID: 35764774 DOI: 10.1007/s40262-022-01137-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
Cefepime is a broad-spectrum fourth-generation cephalosporin with activity against Gram-positive and Gram-negative pathogens. It is generally administered as an infusion over 30-60 min or as a prolonged infusion with infusion times from 3 h to continuous administration. Cefepime is widely distributed in biological fluids and tissues with an average volume of distribution of ~ 0.2 L/kg in healthy adults with normal renal function. Protein binding is relatively low (20%), and elimination is mainly renal. About 85% of the dose is excreted unchanged in the urine, with an elimination half-life of 2-2.3 h. The pharmacokinetics of cefepime is altered under certain pathophysiological conditions, resulting in high inter-individual variability in cefepime volume of distribution and clearance, which poses challenges for population dosing approaches. Consequently, therapeutic drug monitoring of cefepime may be beneficial in certain patients including those who are critically ill, have life-threatening infections, or are infected with more resistant pathogens. Cefepime is generally safe and efficacious, with a goal exposure target of 70% time of the free drug concentration over the minimum inhibitory concentration for clinical efficacy. In recent years, reports of neurotoxicity have increased, specifically in patients with impaired renal function. This review summarizes the pharmacokinetics, pharmacodynamics, and toxicodynamics of cefepime contemporarily in the setting of increasing cefepime exposures. We explore the potential benefits of extended or continuous infusions and therapeutic drug monitoring in special populations.
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Affiliation(s)
- Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA.,Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA.,Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | | | - Gideon Stitt
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin J Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA.,Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Emily Lesnicki
- College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Vaidehi Panchal
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - Maria Bruzzone
- Division of Neurology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Argyle V Bumanglag
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA.,Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sara N Burke
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA.,Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA. .,Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA.
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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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Shah S, Bland S. Cefepime-Induced Encephalopathy With Seizures in a Pediatric Patient With End-Stage Renal Disease Rapidly Reversed by High-Efficiency Hemodialysis. Cureus 2021; 13:e13842. [PMID: 33717772 PMCID: PMC7954516 DOI: 10.7759/cureus.13842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cefepime-induced encephalopathy with associated complications is a relatively rare but known adverse reaction that appears to occur more commonly in the elderly population with concomitant renal dysfunction or pre-existing central nervous system disease. The description of neurological features in pediatric patients secondary to cefepime-induced encephalopathy has rarely been reported, often delaying diagnosis and treatment. We report a 13-year-old female with end-stage renal disease, maintained on hemodialysis, who developed acute neurological symptoms of aphasia, myoclonus, hallucinations, seizures, and altered mental status after two days of cefepime treatment. After prompt discontinuation of cefepime and urgent hemodialysis, the neurological symptoms were resolved. Our patient had complete neurological recovery within 24 hours of the initial presentation of neurological symptoms. Recognizing the possibility of encephalopathy related to cefepime administration in high-risk pediatric patients should prompt close neurological monitoring when under treatment. Hemodialysis may help rapidly reverse the symptoms of cefepime-induced encephalopathy.
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Affiliation(s)
- Siddharth Shah
- Pediatric Nephrology, Norton Children's Hospital and University of Louisville, Louisville, USA
| | - Stephanie Bland
- Pediatrics, Norton Children's Hospital and University of Louisville, Louisville, USA
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Costenaro P, Minotti C, Cuppini E, Barbieri E, Giaquinto C, Donà D. Optimizing Antibiotic Treatment Strategies for Neonates and Children: Does Implementing Extended or Prolonged Infusion Provide any Advantage? Antibiotics (Basel) 2020; 9:antibiotics9060329. [PMID: 32560411 PMCID: PMC7344997 DOI: 10.3390/antibiotics9060329] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/09/2020] [Accepted: 06/12/2020] [Indexed: 12/25/2022] Open
Abstract
Optimizing the use of antibiotics has become mandatory, particularly for the pediatric population where limited options are currently available. Selecting the dosing strategy may improve overall outcomes and limit the further development of antimicrobial resistance. Time-dependent antibiotics optimize their free concentration above the minimal inhibitory concentration (MIC) when administered by continuous infusion, however evidences from literature are still insufficient to recommend its widespread adoption. The aim of this review is to assess the state-of-the-art of intermittent versus prolonged intravenous administration of antibiotics in children and neonates with bacterial infections. We identified and reviewed relevant literature by searching PubMed, from 1 January 1 2000 to 15 April 2020. We included studies comparing intermittent versus prolonged/continuous antibiotic infusion, among the pediatric population. Nine relevant articles were selected, including RCTs, prospective and retrospective studies focusing on different infusion strategies of vancomycin, piperacillin/tazobactam, ceftazidime, cefepime and meropenem in the pediatric population. Prolonged and continuous infusions of antibiotics showed a greater probability of target attainment as compared to intermittent infusion regimens, with generally good clinical outcomes and safety profiles, however its impact in terms on efficacy, feasibility and toxicity is still open, with few studies led on children and adult data not being fully extendable.
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Affiliation(s)
- Paola Costenaro
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Chiara Minotti
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Elena Cuppini
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Elisa Barbieri
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
| | - Carlo Giaquinto
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
- Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
- Paediatric Network for Treatment of AIDS (Penta) Foundation, 35128 Padua, Italy
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Women's and Children's Health, University of Padova, 35128 Padova, Italy
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Zhao Y, Yao BF, Kou C, Xu HY, Tang BH, Wu YE, Hao GX, Zhang XP, Zhao W. Developmental Population Pharmacokinetics and Dosing Optimization of Cefepime in Neonates and Young Infants. Front Pharmacol 2020; 11:14. [PMID: 32116695 PMCID: PMC7010644 DOI: 10.3389/fphar.2020.00014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/07/2020] [Indexed: 11/13/2022] Open
Abstract
Objective Cefepime is used to treat severe infections in neonates. Pharmacokinetic data have only been evaluated among preterm neonates and population pharmacokinetic model lacked external validation. Hence, our aim is to obtain the population pharmacokinetic parameters of cefepime with large sampling and optimize the cefepime dosage regimen for neonatal infection based on developmental pharmacokinetics–pharmacodynamics. Methods Blood samples from neonates and young infants treated with cefepime were collected using the opportunistic sampling design. The concentration of cefepime was determined using high performance liquid chromatography with ultraviolet detection. The population pharmacokinetic model was established using NONMEM software. Results One hundred blood samples from eighty-five neonates were analyzed. The population pharmacokinetics of cefepime were described by a one-compartment model with first-order elimination. Covariate analysis indicated that serum creatinine concentration, postmenstrual age and current weight had significant impact on the pharmacokinetic parameters of cefepime. Monte Carlo simulation results showed that the current dosage regimen (30 mg/kg, q12 h) had a high risk of insufficient dose. For 70% of neonates to obtain a higher free drug concentration than the minimum inhibitory concentration during 70% of the dosing interval, 50 mg/kg q12 h was needed with a susceptibility breakpoint of 4 mg/l. For a minimum inhibitory concentration of 8 mg/l, 40 mg/kg q8 h was recommended for all neonates. Conclusion A population pharmacokinetic model of cefepime in neonates and young infants was established. According to simulation results based on the developmental pharmacokinetics–pharmacodynamics, different dosage regimens should be given depending on pathogens and the postmenstrual age.
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Affiliation(s)
- Yang Zhao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Chen Kou
- Department of Neonatology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Hai-Yan Xu
- Department of Neonatology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Yue-E Wu
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Xin-Ping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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7
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Tauzin M, Ouldali N, Béchet S, Caeymaex L, Cohen R. Pharmacokinetic and pharmacodynamic considerations of cephalosporin use in children. Expert Opin Drug Metab Toxicol 2019; 15:869-880. [PMID: 31597049 DOI: 10.1080/17425255.2019.1678585] [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: 10/25/2022]
Abstract
Introduction: Cephalosporins are a major class of antibiotics, frequently used in children because of their remarkable antibacterial activity and excellent safety profile. Time above the minimal inhibitory concentration of the non-protein-bound fraction (fT>MIC) is the pharmacokinetic/pharmacodynamic parameter that correlates with the therapeutic efficacy. In the pediatric population, the inter-individual variability in cephalosporin pharmacokinetics is large because of maturational changes. However, the prescription of cephalosporins promotes emergence of Enterobacteriaceae producing broad-spectrum ß-lactamases.Areas covered: Here we describe in vitro activities and the main pharmacokinetic characteristics of cephalosporins in children. On the basis of these characteristics, we propose an estimation of the fT>MIC for each molecule as a tool to help optimize the use of cephalosporins. We also provide an inventory of the clinical use of cephalosporins and present prospects for the development of new molecules or associations to address the emergence of resistant strains.Expert opinion: Cephalosporins represent a heterogeneous group of antibiotics with various pharmacokinetics and in vitro antimicrobial activity that the clinician needs to master to optimize their use. However, their broad use plays a role in the emergence of broad-spectrum ß-lactamase-producing strains and must thus be restricted to probabilistic broad-spectrum therapy and situations without therapeutic alternatives.
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Affiliation(s)
- Manon Tauzin
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Naim Ouldali
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Créteil, France.,GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Paris, France.,Unité d'Epidémiologie Clinique, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, ECEVE INSERM UMR, Paris, France
| | - Stéphane Béchet
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Créteil, France
| | - Laurence Caeymaex
- Neonatal Intensive Care Unit, Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Paris-Est Créteil University, Créteil, France.,Clinical Research Center (CRC), Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Robert Cohen
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Créteil, France.,GPIP, Groupe de Pathologie Infectieuse Pédiatrique, Paris, France.,Clinical Research Center (CRC), Centre Hospitalier Intercommunal de Créteil, Créteil, France.,Université Paris Est, IMRB- GRC GEMINI, Créteil, France.,Unité Court séjour Petits Nourrissons, Service de Néonatologie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
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9
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Nichols KR, Israel EN, Thomas CA, Knoderer CA. Optimizing Guideline-Recommended Antibiotic Doses for Pediatric Infective Endocarditis. Ann Pharmacother 2016; 50:423-7. [PMID: 26917819 DOI: 10.1177/1060028016635660] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The American Heart Association recently published an updated scientific statement on the management of infective endocarditis in childhood. The recommendations included for vancomycin, aminoglycoside, and β-lactam dosing and monitoring are based primarily on expert opinion and do not consider available evidence for dose optimization based on pharmacokinetic and pharmacodynamic principles in pediatric patients. This is concerning because even when clinically necessary, some practitioners may be hesitant to deviate from guideline-recommended doses. In this perspective, we highlight potential areas for improvement in the statement-recommended doses and summarize evidence supporting antibiotic dosing optimization. The addition of a pediatric clinical pharmacist with expertise in antibiotic dosing to the panel would be beneficial for future updates.
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Affiliation(s)
- Kristen R Nichols
- Butler University, Indianapolis, IN, USA Indiana University Health, Indianapolis, IN, USA Indiana University School of Medicine, Indianapolis, IN, USA
| | - Emily N Israel
- Indiana University Health, Indianapolis, IN, USA Purdue University, Indianapolis and West Lafayette, IN, USA
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10
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Nichols KR, Karmire LC, Cox EG, Kays MB, Knoderer CA. Implementing extended-infusion cefepime as standard of care in a children's hospital: a prospective descriptive study. Ann Pharmacother 2015; 49:419-26. [PMID: 25614528 DOI: 10.1177/1060028014566447] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Extended-infusion cefepime (EIC) has been associated with decreased mortality in adults, but to our knowledge, there are no studies in children. OBJECTIVE The objective of this study was to determine the feasibility of implementing EIC as the standard dosing strategy in a pediatric population. METHODS This was a descriptive study of children aged 1 month to 17 years, including patients in the intensive care unit, who received cefepime after admission to a freestanding, tertiary care children's hospital. Patients were excluded if they were admitted to the neonatal intensive care unit or received cefepime in the outpatient, operating, or emergency department areas. Demographic and clinical data for patients who received cefepime from April through August 2013, the period following EIC implementation, were extracted from the medical records. RESULTS A total of 150 patients were included in the study, with a median age (interquartile range [IQR]) of 6 years (2-12.3 years) and median weight (IQR) of 20.7 kg (13.2-42.8 kg); 143 patients received cefepime via extended infusions, and 10 (7.0%) of those were changed to a 30-minute infusion during treatment. The most common reasons for infusion time change were intravenous (IV) incompatibility and IV access concerns, responsible for 50% of changes. Dosing errors and reported incidents during therapy were sparse (n = 12, 8.0%) and were most commonly related to renal dosing errors and/or initial dose error by prescriber. CONCLUSIONS Because 93.0% of the patients who initially received EIC remained on EIC, implementation of EIC as the standard dosing strategy was feasible in this pediatric hospital.
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Affiliation(s)
- Kristen R Nichols
- Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA Riley Hospital for Children at IU Health, Indianapolis, IN, USA Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lauren C Karmire
- Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA
| | - Elaine G Cox
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael B Kays
- Purdue University College of Pharmacy, Indianapolis and West Lafayette, IN, USA
| | - Chad A Knoderer
- Butler University College of Pharmacy and Health Sciences, Indianapolis, IN, USA
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Huang H, Huang S, Zhu P, Xi X. Continuous versus intermittent infusion of cefepime in neurosurgical patients with post-operative intracranial infections. Int J Antimicrob Agents 2013; 43:68-72. [PMID: 24139880 DOI: 10.1016/j.ijantimicag.2013.08.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Revised: 08/08/2013] [Accepted: 08/16/2013] [Indexed: 10/26/2022]
Abstract
Cefepime is administered as an intermittent infusion (II); however, continuous infusion (CI) may be advantageous because β-lactam antibiotics exhibit time-dependent antibacterial activity. This retrospective, non-randomised, comparative study included 68 neurosurgical patients with post-operative intracranial infections treated with 4g/day cefepime over 24h as a CI (n=34) or 2g every 12h as II (n=34). CI controlled the intracranial infection more rapidly and effectively than II (6.6±1.9 days vs. 7.8±2.6 days; P=0.036). By considering the minimum inhibitory concentrations (MICs) to be 4μg/mL and 8μg/mL, the percentage of time when the cefepime plasma or CSF concentrations were higher than the MIC (%T>MIC) was calculated for each patient. For plasma cefepime concentrations, the %T(>MIC) in the CI group was higher than in the II group (for MICs of 8μg/mL, 100% vs. 75%, respectively). The mean calculated area under the curve (AUC) in the CI group was similar to the II group (1197.99±72.15μgh/mL vs. 890.84±140.78μgh/mL; P=0.655). For CSF cefepime concentrations, the %T(>MIC) in the CI group was higher than in the II group (for MICs of 4μg/mL and 8μg/mL, 83.3% and 75% vs. 25% and 0%, respectively). The mean calculated AUC for the CI group was higher than the II group (220.56±13.59μgh/mL vs. 86.34±5.69μgh/mL; P=0.003). Therefore, CI of cefepime significantly enhanced the antibacterial effect and reduced the treatment duration in neurosurgical patients with post-operative intracranial infections.
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Affiliation(s)
- Huawei Huang
- Department of Critical Care Medicine, Beijing Fuxing Hospital, Capital Medical University, Beijing 100038, PR China
| | - Shengyue Huang
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian Medical University, Fuzhou 350001, PR China
| | - Pengli Zhu
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fuzhou 350001, PR China.
| | - Xiuming Xi
- Department of Critical Care Medicine, Beijing Fuxing Hospital, Capital Medical University, Beijing 100038, PR China.
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Abstract
UNLABELLED Cefepime (Maxipime), Maxcef, Cepimax, Cepimex, Axepim, a parenteral fourth-generation cephalosporin, is active against many organisms causative in pneumonia. Cefepime has in vitro activity against Gram-positive organisms including Staphylococcus aureus and penicillin-sensitive, -intermediate and -resistant Streptococcus pneumoniae similar to that of cefotaxime and ceftriaxone. Cefepime also has good activity against Gram-negative organisms, including Pseudomonas aeruginosa, similar to that of ceftazidime. Importantly, cefepime is stable against many of the common plasmid- and chromosome-mediated beta-lactamases and is a poor inducer of AmpC beta-lactamases. As a result, it retains activity against Enterobacteriaceae that are resistant to third-generation cephalosporins, such as derepressed mutants of Enterobacter spp. Cefepime may be hydrolyzed by the extended-spectrum beta-lactamases produced by some members of the Enterobacteriaceae, but to a lesser extent than the third-generation cephalosporins. Monotherapy with cefepime 1 or 2g, usually administered intravenously twice daily, was as effective for clinical and bacteriological response as ceftazidime, ceftriaxone or cefotaxime monotherapy (1 or 2g two or three times daily) in a number of randomized, clinical trials in hospitalized adult, or less commonly, pediatric, patients with generally moderate to severe community-acquired or nosocomial pneumonia. More limited data indicated that monotherapy with cefepime 2g three times daily was also as effective in treating patients with nosocomial pneumonia as imipenem/cilostatin 0.5g four times daily, and when combined with amikacin, cefepime was as effective as ceftazidime plus amikacin. Patients with pneumonia who failed to respond to previous antibacterial therapy with penicillins or other cephalosporins responded to treatment with cefepime. Cefepime is generally well tolerated, with a tolerability profile similar to those of other parenteral cephalosporins. In clinical trials, the majority of adverse events experienced by cefepime recipients were mild to moderate and reversible. The most common adverse events with a causal relationship to cefepime reported in clinical trials included rash and diarrhea. Other, less common, adverse events included pruritus, urticaria, nausea, vomiting oral candidiasis, colitis, headache, fever, erythema and vaginitis. CONCLUSION Cefepime is an established and generally well tolerated parenteral drug with a broad spectrum of antibacterial activity which, when administered twice daily, provides coverage of most of the pathogens that may be causative in pneumonia. In randomized clinical trials in hospitalized patients with generally moderate to severe community-acquired or nosocomial pneumonia, cefepime monotherapy exhibited good clinical and bacteriological efficacy. Cefepime may become a preferred antibacterial agent for infections caused by Enterobacter spp. With prudent use in order to prevent the emergence of resistant organisms, cefepime will continue to be a suitable option for the empiric treatment of pneumonia.
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13
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Endimiani A, Perez F, Bonomo RA. Cefepime: a reappraisal in an era of increasing antimicrobial resistance. Expert Rev Anti Infect Ther 2008; 6:805-24. [PMID: 19053894 PMCID: PMC2633657 DOI: 10.1586/14787210.6.6.805] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cefepime is a 'fourth-generation' cephalosporin with an in vitro extended-spectrum of activity against Gram-negative and Gram-positive pathogens. Cefepime is approved for the treatment of moderate-to-severe infections, such as pneumonia, uncomplicated and complicated urinary tract infections, skin and soft-tissue infections, intra-abdominal infections and febrile neutropenia. In this article, we provide a critical review of pharmacodynamics, clinical management, pharmacokinetics, metabolism, pharmacodynamic target analyses, clinical efficacy, safety and tolerability of cefepime after more than a decade of clinical use.
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Affiliation(s)
- Andrea Endimiani
- Department of Medicine, Section of Infectious Diseases, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
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Lima-Rogel V, Medina-Rojas EL, Del Carmen Milán-Segovia R, Noyola DE, Nieto-Aguirre K, López-Delarosa A, Romano-Moreno S. Population pharmacokinetics of cefepime in neonates with severe nosocomial infections. J Clin Pharm Ther 2008; 33:295-306. [PMID: 18452417 DOI: 10.1111/j.1365-2710.2008.00913.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To define the pharmacokinetic behaviour of cefepime in neonates with severe nosocomial infections using a mixed effects model. PATIENTS AND METHODS Thirty-one newborn infants were included in the study; 10 additional infants participated in the validation of the pharmacokinetic model. Cefepime CL and V were determined using an open monocompartmental model with first-order elimination. The influence of demographic and clinical characteristics on the model was evaluated. The non-linear mixed effect model (nonmem) program was used to determine the pharmacokinetic population model. RESULTS The mean corrected gestational age for infants participating in the construction and validation of the model were 35 and 33 weeks, respectively. Factors included in the final pharmacokinetic model were body surface area (BSA) and calculated CL(CR). The final population model was CL (L/h) = 0.457 BSA (m(2)) + 0.243 CL(CR) (L/h) and V(L) = 4.12 BSA (m(2)). This model explains 33.3% of the interindividual variability for CL and 12.8% for V. This model was validated in ten neonates with nosocomial infections by assessing the predictive capacity of plasma cefepime concentrations using a priori and Bayesian strategies. CONCLUSIONS The predictive performance of this population model for cefepime plasma concentrations was adequate for clinical purposes and can be used for individualizing cefepime therapy in newborn infants with severe infections. Cefepime plasma concentrations can be predicted based on BSA and calculated CL(CR). Cefepime therapy using a 250 mg/m(2) dose administered every 12 h is adequate to achieve plasma concentrations greater than 8 mug/mL during more than 60% of the dosing interval and is expected to be effective in the treatment of bloodstream infections caused by most gram negative organisms in newborn infants. A dose of 550 mg/m(2) would be required for the treatment of infections caused by Pseudomonas sp.
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Affiliation(s)
- V Lima-Rogel
- Department of Pediatrics, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico.
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Tom-Revzon C. Erratic absorption of intramuscular antimicrobial delivery in infants and children. Expert Opin Drug Metab Toxicol 2008; 3:733-40. [PMID: 17916058 DOI: 10.1517/17425255.3.5.733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the absence of intravenous or enteral access, an intramuscular (IM) injection of medications is a viable alternative. Vaccines, antibiotics and analgesics are commonly administered by this route in pediatric medicine to enhance adherence to regimens. Although it is expected that the entire dose be administered by the IM route, the absorption (rate and extent) of the medication from the muscle tissue into systemic circulation can be erratic and depends on the drug's physicochemical factors and patient-specific factors. Despite the variability in absorption, administration of medications by the IM route may be considered when medications do not need to attain maximal concentrations rapidly. IM injections are generally well-tolerated, but potential injury to the injected muscle and the proximal nerves should be recognized.
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Affiliation(s)
- Catherine Tom-Revzon
- Long Island University, Division of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Brooklyn, New York 11201, USA.
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Jones RN, Sader HS, Fritsche TR, Pottumarthy S. Comparisons of parenteral broad-spectrum cephalosporins tested against bacterial isolates from pediatric patients: report from the SENTRY Antimicrobial Surveillance Program (1998–2004). Diagn Microbiol Infect Dis 2007; 57:109-16. [PMID: 16930923 DOI: 10.1016/j.diagmicrobio.2006.06.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A contemporary collection of 12737 strains from pediatric patients (<18 years) isolated over a 7-year period (1998-2004) from 52 sentinel hospitals in North America was tested to determine the comparative antimicrobial potency of broad-spectrum parenteral cephalosporins and selected comparator agents. Most of the strains (84.1%) were isolated from blood stream or respiratory tract infections. The rank order of the top 10 pediatric pathogens analyzed was Streptococcus pneumoniae (15.5%) >Haemophilus influenzae (14.6%) >Staphylococcus aureus (13.8%) >Moraxella catarrhalis = coagulase-negative staphylococci (8.0%) >Escherichia coli (7.8%) >Pseudomonas aeruginosa (5.2%) >Klebsiella spp. (4.8%) >Enterococcus spp. (4.7%) > beta-hemolytic streptococci (4.4%). Both cefepime and ceftriaxone (MIC(90), 1 microg/mL; 93.9% and 93.7% susceptible, respectively) were highly active against S. pneumoniae. However, the S. pneumoniae strains showed reduced susceptibility to ceftazidime (56.6%), as well as penicillin (56.6%) < trimethoprim-sulfamethoxazole (57.1%) < erythromycin (66.2%) < tetracycline (71.4%). beta-Hemolytic streptococci showed 100.0% susceptibility to penicillin, cefepime, and ceftriaxone. Cefepime and ceftriaxone exhibited high activity against oxacillin (methicillin)-susceptible S. aureus, (MIC(90), 4 microg/mL; 100.0% and 99.8% susceptible, respectively), whereas ceftazidime (MIC(90), 16 microg/mL) was active against only 86.7% of strains. H. influenzae strains showed complete susceptibility to cefepime, ceftriaxone, and levofloxacin (MIC(90), < or =0.5 microg/mL; 100.0%), and 34.0% of H. influenzae and 99.2% of M. catarrhalis strains produced beta-lactamase. Although the 3 cephalosporins tested (cefepime, ceftriaxone, and ceftazidime) were very active (98.6-99.6% susceptible) against E. coli, cefepime (99.0% susceptible) was slightly more active than ceftriaxone and ceftazidime (96.4% and 95.1% susceptible, respectively) against Klebsiella spp. Cefepime was also the most active beta-lactam agent tested against Enterobacter spp. (MIC(90), 2 microg/mL; 99.3% susceptible), whereas the susceptibility rates of other broad-spectrum beta-lactams (ceftriaxone, ceftazidime and piperacillin-tazobactam) were significantly lower (78.4-81.5%). Against P. aeruginosa, imipenem and piperacillin-tazobactam showed the highest susceptibility rates (94.4% and 93.3%, respectively), whereas imipenem and cefepime showed the lowest resistance rates (1.4% and 2.3%, respectively). Our results indicate that cefepime was the most broad-spectrum cephalosporin analyzed and remains a very potent alternative for the treatment of contemporary pediatric infections in North America.
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Affiliation(s)
- Ronald N Jones
- JMI Laboratories, 345 Beaver Kreek Centre, North Liberty, IA 52317, USA.
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Chen YR, Lin SJ, Chou YW, Wu HL, Chen SH. Simultaneous determination of cefepime and L-arginine by micellar electrokinetic chromato- graphy and applications to commercial injections. J Sep Sci 2005; 28:2173-9. [PMID: 16318214 DOI: 10.1002/jssc.200500081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A simple micellar electrokinetic chromatography (MEKC) with UV detection is described for simultaneous analysis of cefepime and L-arginine. The determination of cefepime and L-arginine in pharmaceutical preparations was performed at 25degreesC using a background electrolyte consisting of Tris buffer with sodium dodecyl sulfate (SDS) as the electrolyte solution. Several parameters affecting the separation of the drugs were studied, including the pH and concentrations of the Tris buffer and SDS. Under optimal MEKC conditions, good separation with high efficiency and short analysis times is achieved. Using cefazolin as an internal standard, the linear ranges of the method for the determination of cefepime and L-arginine were over 5-100 microg/mL; the detection limits of cefepime (signal to noise ratio = 3; injection 3.45 kPa, 3 s) and L-arginine (signal to noise ratio = 3; injection 3.45 kPa, 3 s) were 2 microg/mL and 4 microg/ mL, respectively. Applicability of the proposed method for the determination of cefepime and L-arginine in commercial injections was demonstrated.
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Affiliation(s)
- Yi-Ru Chen
- Graduate Institute of Pharmaceutical Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
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Haase MR. Acute Bacterial Meningitis in Children. J Pharm Pract 2004. [DOI: 10.1177/0897190004270422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite advances in recent decades in management, including new and effective antimicrobials, children with bacterial meningitis still incur significant morbidity and mortality. Pathophysiologic processes including colonization and migration of the bacteria to blood, seeding of the meninges, and meningeal and brain inflammation have been largely elucidated, but more specific knowledge could lead to new effective therapies. Outside of the neonatal period, the most common causative organisms have been Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis. However, conjugate vaccines, especially the H influenzae type b preparation, have contributed significantly to steep declines in the incidence of meningitis. Optimal management consists of rapid diagnosis and administration of bactericidal antibiotics with properties allowing adequate penetration of the inflamed blood-brain barrier. Recently, development of microbial resistance has resulted in changes to recommended empiric antibiotic regimens. Novel therapies are under investigation; however, until controlled trials can be conducted, these therapies cannot be recommended.
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Affiliation(s)
- Mark R. Haase
- Texas Tech University, HSC School of Pharmacy, 1300 S. Coulter, Suite 206, Amarillo, TX 79106-1712
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Veltri MA, Neu AM, Fivush BA, Parekh RS, Furth SL. Drug dosing during intermittent hemodialysis and continuous renal replacement therapy : special considerations in pediatric patients. Paediatr Drugs 2004; 6:45-65. [PMID: 14969569 DOI: 10.2165/00148581-200406010-00004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Chronic renal failure is, fortunately, an unusual occurrence in children; however, many children with various underlying illnesses develop acute renal failure, and transiently require renal replacement therapy - peritoneal dialysis, intermittent hemodialysis (IHD), or continuous renal replacement therapy (CRRT). As children with acute and chronic renal failure often have multiple comorbid conditions requiring drug therapy, generalists, intensivists, nephrologists, and pharmacists need to be aware of the issues surrounding the management of drug therapy in pediatric patients undergoing renal replacement therapy. This article summarizes the pharmacokinetics and dosing of many drugs commonly prescribed for pediatric patients, and focuses on the management of drug therapy in pediatric patients undergoing IHD and CRRT in the intensive care unit setting. Peritoneal dialysis is not considered in this review. Finally, a summary table with recommended initial dosages for drugs commonly encountered in pediatric patients requiring IHD or CRRT is presented.
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Affiliation(s)
- Michael A Veltri
- Pediatric Division, Department of Pharmacy, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-6180, USA.
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Abstract
BACKGROUND Urinary tract infections (UTIs) are common in childhood. They represent a significant proportion (10%) of hospital-acquired infections in children. Bacteria causing UTIs in children vary, depending on the setting (community-acquired vs. nosocomial), underlying anatomic anomalies and concurrent medical conditions. OBJECTIVE To review published and unpublished clinical studies that have used cefepime for the treatment of UTIs in children. METHODS AND RESULTS In two recent multicenter, randomized trials, cefepime (50 mg/kg/dose every 8 h and every 12 h) was compared with ceftazidime (50 mg/kg/dose every 8 h) for the treatment of serious urinary tract infections including pyelonephritis in children less than 12 years of age. In these studies a favorable clinical and microbiologic response was observed in >95% of cefepime-treated and ceftazidime-treated children assessed at the end of treatment. CONCLUSIONS These results indicate that cefepime represents an important therapeutic option for the treatment of serious UTIs in children.
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Affiliation(s)
- A C Arrieta
- Pediatric Infectious Diseases Division, Children's Hospital of Orange County, Orange, CA 92868, USA.
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