1
|
Holford N, O'Hanlon CJ, Allegaert K, Anderson B, Falcão A, Simon N, Lo YL, Thomson AH, Sherwin CM, Jacqz-Aigrain E, Llanos-Paez C, Hennig S, Mockus L, Kirkpatrick C. A physiological approach to renal clearance: From premature neonates to adults. Br J Clin Pharmacol 2023. [PMID: 38031322 DOI: 10.1111/bcp.15978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/13/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023] Open
Abstract
AIMS We propose using glomerular filtration rate (GFR) as the physiological basis for distinguishing components of renal clearance. METHODS Gentamicin, amikacin and vancomycin are thought to be predominantly excreted by the kidneys. A mixed-effects joint model of the pharmacokinetics of these drugs was developed, with a wide dispersion of weight, age and serum creatinine. A dataset created from 18 sources resulted in 27,338 drug concentrations from 9,901 patients. Body size and composition, maturation and renal function were used to describe differences in drug clearance and volume of distribution. RESULTS This study demonstrates that GFR is a predictor of two distinct components of renal elimination clearance: (1) GFR clearance associated with normal GFR and (2) non-GFR clearance not associated with normal GFR. All three drugs had GFR clearance estimated as a drug-specific percentage of normal GFR (gentamicin 39%, amikacin 90% and vancomycin 57%). The total clearance (sum of GFR and non-GFR clearance), standardized to 70 kg total body mass, 176 cm, male, renal function 1, was 5.58 L/h (95% confidence interval [CI] 5.50-5.69) (gentamicin), 7.77 L/h (95% CI 7.26-8.19) (amikacin) and 4.70 L/h (95% CI 4.61-4.80) (vancomycin). CONCLUSIONS GFR provides a physiological basis for renal drug elimination. It has been used to distinguish two elimination components. This physiological approach has been applied to describe clearance and volume of distribution from premature neonates to elderly adults with a wide dispersion of size, body composition and renal function. Dose individualization has been implemented using target concentration intervention.
Collapse
Affiliation(s)
- Nick Holford
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Conor J O'Hanlon
- Department of Pharmacology & Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Brian Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Amilcar Falcão
- Faculty of Pharmacy, Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, Coimbra, Portugal
| | - Nicolas Simon
- Aix Marseille Univ, Hop Sainte Marguerite, Service de Pharmacologie clinique, Marseille, France
| | - Yoke-Lin Lo
- Department of Pharmacy Practice, School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Alison H Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Catherine M Sherwin
- University of Otago, Dunedin, New Zealand
- University of Utah, Salt Lake City, Utah, USA
- Department of Pediatrics, Wright State University Boonshoft School of Medicine/Dayton Children's Hospital, Dayton, Ohio, USA
| | - Evelyne Jacqz-Aigrain
- Paediatric Pharmacology and Pharmacogenetics, APHP Hôpital Saint-Louis - University Paris Cité, Paris, France
| | | | - Stefanie Hennig
- University of Queensland, Brisbane, Australia
- Certara, Inc., Princeton, New Jersey, USA
| | - Linas Mockus
- Chemical Engineering Department, Purdue University, West Lafayette, Indiana, USA
| | - Carl Kirkpatrick
- Monash Institute of Pharmaceutical Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| |
Collapse
|
2
|
Severino N, Urzúa S, Ibacache M, Paulos C, Cortínez L, Toso A, Leguizamon L, Inojosa R, Maccioni A, Meza S, García A, Ramírez M, Von Mentlen C, Ceballos J, Paredes N. Population pharmacokinetics of amikacin in suspected cases of neonatal sepsis. Br J Clin Pharmacol 2023; 89:2254-2262. [PMID: 36811146 DOI: 10.1111/bcp.15697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/06/2023] [Accepted: 02/09/2023] [Indexed: 02/24/2023] Open
Abstract
AIMS This study aimed to characterize the population pharmacokinetic parameters of intravenously administered amikacin in newborns and assess the effect of sepsis in amikacin exposure. METHODS Newborns aged ≥3 days who received at least 1 dose of amikacin during their hospitalization period were eligible for the study. Amikacin was administered intravenously during a 60-min infusion period. Three venous blood samples were taken from each patient during the first 48 h. Population pharmacokinetic parameter estimates were obtained using a population approach with the programme NONMEM. RESULTS Data from 329 drug assay samples were obtained from 116 newborn patients (postmenstrual age [PMA] 38.3, range 32-42.4 weeks; weight 2.8, range 1.6-3.8 kg). Measured amikacin concentrations ranged from 0.8 to 56.4 mg/L. A 2-compartment model with linear elimination produced a good fit of the data. Estimated parameters for a typical subject (2.8 kg, 38.3 weeks) were clearance (Cl = 0.16 L/h), intercompartmental clearance (Q = 0.15 L/h), volume of distribution of the central compartment (Vc = 0.98 L) and peripheral volume of distribution (Vp = 1.23 L). Total bodyweight, PMA and the presence of sepsis positively influenced Cl. Plasma creatinine concentration and circulatory instability (shock) negatively influenced Cl. CONCLUSION Our main results confirm previous findings showing that weight, PMA and renal function are relevant factors influencing newborn amikacin pharmacokinetics. In addition, current results showed that pathophysiological states of critically ill neonates, such as sepsis and shock, were associated with opposite effects in amikacin clearance and should be considered in dose adjustments.
Collapse
Affiliation(s)
- Nicolas Severino
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Programa de Farmacología y Toxicología, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Departamento de Medicina Intensiva, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Soledad Urzúa
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Neonatología, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mauricio Ibacache
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- División de Anestesiología, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Claudio Paulos
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Facultad de Química y Farmacia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Luis Cortínez
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- División de Anestesiología, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Alberto Toso
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Neonatología, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Liliana Leguizamon
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Neonatología, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rocío Inojosa
- Departamento de Neonatología, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Complejo Asistencial Doctor Sotero del Río, Puente Alto, Chile
| | - Andrea Maccioni
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Neonatología, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Complejo Asistencial Doctor Sotero del Río, Puente Alto, Chile
| | - Sebastián Meza
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Facultad de Química y Farmacia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Andrés García
- Laboratorio Clínico, Red de Salud UC-Christus, Chile
| | - Marcelo Ramírez
- Complejo Asistencial Doctor Sotero del Río, Puente Alto, Chile
| | - Catalina Von Mentlen
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Facultad de Química y Farmacia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Javiera Ceballos
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Facultad de Química y Farmacia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Noemí Paredes
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Facultad de Química y Farmacia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| |
Collapse
|
3
|
Kerling DA, Clarke SC, DeLuca JP, Evans MO, Kress AT, Nadeau RJ, Selig DJ. Systematic Review and Meta-Analysis of the Effect of Loop Diuretics on Antibiotic Pharmacokinetics. Pharmaceutics 2023; 15:pharmaceutics15051411. [PMID: 37242653 DOI: 10.3390/pharmaceutics15051411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Loop diuretics and antibiotics are commonly co-prescribed across many clinical care settings. Loop diuretics may alter antibiotic pharmacokinetics (PK) via several potential drug interactions. A systematic review of the literature was performed to investigate the impact of loop diuretics on antibiotic PK. The primary outcome metric was the ratio of means (ROM) of antibiotic PK parameters such as area under the curve (AUC) and volume of distribution (Vd) on and off loop diuretics. Twelve crossover studies were amenable for metanalysis. Coadministration of diuretics was associated with a mean 17% increase in plasma antibiotic AUC (ROM 1.17, 95% CI 1.09-1.25, I2 = 0%) and a mean decrease in antibiotic Vd by 11% (ROM 0.89, 95% CI 0.81-0.97, I2 = 0%). However, the half-life was not significantly different (ROM 1.06, 95% CI 0.99-1.13, I2 = 26%). The remaining 13 observational and population PK studies were heterogeneous in design and population, as well as prone to bias. No large trends were collectively observed in these studies. There is currently not enough evidence to support antibiotic dosing changes based on the presence or absence of loop diuretics alone. Further studies designed and powered to detect the effect of loop diuretics on antibiotic PK are warranted in applicable patient populations.
Collapse
Affiliation(s)
- David A Kerling
- Walter Reed National Military Medical Center, Internal Medicine, Bethesda, MD 20889, USA
| | - Sarah C Clarke
- Walter Reed National Military Medical Center, Internal Medicine, Bethesda, MD 20889, USA
| | - Jesse P DeLuca
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Martin O Evans
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Adrian T Kress
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Robert J Nadeau
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| | - Daniel J Selig
- Walter Reed Army Institute of Research, Clinical Pharmacology Fellowship, Silver Spring, MD 20910, USA
| |
Collapse
|
4
|
Nguyen TA, Kirubakaran R, Schultz HB, Wong S, Reuter SE, McMullan B, Bolisetty S, Campbell C, Horvath AR, Stocker SL. Analytical and Non-Analytical Variation May Lead to Inappropriate Antimicrobial Dosing in Neonates: An In Silico Study. Clin Chem 2023:7146664. [PMID: 37116191 DOI: 10.1093/clinchem/hvad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/01/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of aminoglycosides and vancomycin is used to prevent oto- and nephrotoxicity in neonates. Analytical and nonanalytical factors potentially influence dosing recommendations. This study aimed to determine the impact of analytical variation (imprecision and bias) and nonanalytical factors (accuracy of drug administration time, use of non-trough concentrations, biological variation, and dosing errors) on neonatal antimicrobial dosing recommendations. METHODS Published population pharmacokinetic models and the Australasian Neonatal Medicines Formulary were used to simulate antimicrobial concentration-time profiles in a virtual neonate population. Laboratory quality assurance data were used to quantify analytical variation in antimicrobial measurement methods used in clinical practice. Guideline-informed dosing recommendations based on drug concentrations were applied to compare the impact of analytical variation and nonanalytical factors on antimicrobial dosing. RESULTS Analytical variation caused differences in subsequent guideline-informed dosing recommendations in 9.3-12.1% (amikacin), 16.2-19.0% (tobramycin), 12.2-45.8% (gentamicin), and 9.6-19.5% (vancomycin) of neonates. For vancomycin, inaccuracies in drug administration time (45.6%), use of non-trough concentrations (44.7%), within-subject biological variation (38.2%), and dosing errors (27.5%) were predicted to result in more dosing discrepancies than analytical variation (12.5%). Using current analytical performance specifications, tolerated dosing discrepancies would be up to 14.8% (aminoglycosides) and 23.7% (vancomycin). CONCLUSIONS Although analytical variation can influence neonatal antimicrobial dosing recommendations, nonanalytical factors are more influential. These result in substantial variation in subsequent dosing of antimicrobials, risking inadvertent under- or overexposure. Harmonization of measurement methods and improved patient management systems may reduce the impact of analytical and nonanalytical factors on neonatal antimicrobial dosing.
Collapse
Affiliation(s)
- Thi A Nguyen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Ranita Kirubakaran
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
- Seberang Jaya Hospital, Penang, Malaysia
| | - Hayley B Schultz
- UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Sherilyn Wong
- UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Stephanie E Reuter
- UniSA: Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Brendan McMullan
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Randwick, NSW, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Srinivas Bolisetty
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Craig Campbell
- NSW Health Pathology, Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Andrea R Horvath
- Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- NSW Health Pathology, Department of Chemical Pathology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Sophie L Stocker
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital, Sydney, NSW, Australia
| |
Collapse
|
5
|
Evaluating and Improving Neonatal Gentamicin Pharmacokinetic Models Using Aggregated Routine Clinical Care Data. Pharmaceutics 2022; 14:pharmaceutics14102089. [PMID: 36297524 PMCID: PMC9609639 DOI: 10.3390/pharmaceutics14102089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Model-informed precision dosing (MIPD) can aid dose decision-making for drugs such as gentamicin that have high inter-individual variability, a narrow therapeutic window, and a high risk of exposure-related adverse events. However, MIPD in neonates is challenging due to their dynamic development and maturation and by the need to minimize blood sampling due to low blood volume. Here, we investigate the ability of six published neonatal gentamicin population pharmacokinetic models to predict gentamicin concentrations in routine therapeutic drug monitoring from nine sites in the United State (n = 475 patients). We find that four out of six models predicted with acceptable levels of error and bias for clinical use. These models included known important covariates for gentamicin PK, showed little bias in prediction residuals over covariate ranges, and were developed on patient populations with similar covariate distributions as the one assessed here. These four models were refit using the published parameters as informative Bayesian priors or without priors in a continuous learning process. We find that refit models generally reduce error and bias on a held-out validation data set, but that informative prior use is not uniformly advantageous. Our work informs clinicians implementing MIPD of gentamicin in neonates, as well as pharmacometricians developing or improving PK models for use in MIPD.
Collapse
|
6
|
Simeoli R, Cairoli S, Decembrino N, Campi F, Dionisi Vici C, Corona A, Goffredo BM. Use of Antibiotics in Preterm Newborns. Antibiotics (Basel) 2022; 11:antibiotics11091142. [PMID: 36139921 PMCID: PMC9495226 DOI: 10.3390/antibiotics11091142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Due to complex maturational and physiological changes that characterize neonates and affect their response to pharmacological treatments, neonatal pharmacology is different from children and adults and deserves particular attention. Although preterms are usually considered part of the neonatal population, they have physiological and pharmacological hallmarks different from full-terms and, therefore, need specific considerations. Antibiotics are widely used among preterms. In fact, during their stay in neonatal intensive care units (NICUs), invasive procedures, including central catheters for parental nutrition and ventilators for respiratory support, are often sources of microbes and require antimicrobial treatments. Unfortunately, the majority of drugs administered to neonates are off-label due to the lack of clinical studies conducted on this special population. In fact, physiological and ethical concerns represent a huge limit in performing pharmacokinetic (PK) studies on these subjects, since they limit the number and volume of blood sampling. Therapeutic drug monitoring (TDM) is a useful tool that allows dose adjustments aiming to fit plasma concentrations within the therapeutic range and to reach specific drug target attainment. In this review of the last ten years’ literature, we performed Pubmed research aiming to summarize the PK aspects for the most used antibiotics in preterms.
Collapse
Affiliation(s)
- Raffaele Simeoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Sara Cairoli
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Nunzia Decembrino
- Neonatal Intensive Care Unit, University Hospital “Policlinico-San Marco” Catania, Integrated Department for Maternal and Child’s Health Protection, 95100 Catania, Italy
| | - Francesca Campi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Carlo Dionisi Vici
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bianca Maria Goffredo
- Division of Metabolic Diseases and Drug Biology, Bambino Gesù Children’s Hospital, IRCCS, 00146 Rome, Italy
- Correspondence: ; Tel.: +39-0668592174; Fax: + 39-0668593009
| |
Collapse
|
7
|
Hodiamont CJ, van den Broek AK, de Vroom SL, Prins JM, Mathôt RAA, van Hest RM. Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review. Clin Pharmacokinet 2022; 61:1075-1094. [PMID: 35754071 PMCID: PMC9349143 DOI: 10.1007/s40262-022-01143-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.
Collapse
Affiliation(s)
- Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Suzanne L de Vroom
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| |
Collapse
|
8
|
He S, Cheng Z, Xie F. PK/PD guided gentamicin dosing in critically ill patients: a revisit of the Hartford nomogram. Int J Antimicrob Agents 2022; 59:106600. [DOI: 10.1016/j.ijantimicag.2022.106600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/29/2022] [Accepted: 04/28/2022] [Indexed: 11/05/2022]
|
9
|
He S, Cheng Z, Xie F. Population Pharmacokinetics and Dosing Optimization of Gentamicin in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Drug Des Devel Ther 2022; 16:13-22. [PMID: 35023902 PMCID: PMC8747548 DOI: 10.2147/dddt.s343385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/23/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose Appropriate gentamicin dosing in continuous renal replacement therapy (CRRT) patients remains undefined. This study aimed to develop a population pharmacokinetic (PK) model of gentamicin in CRRT patients and to infer the optimal dosing regimen for gentamicin. Methods Fourteen CRRT patients dosed with gentamicin were included to establish a population PK model to characterize the variabilities and influential covariates of gentamicin. The pharmacokinetic/pharmacodynamic (PK/PD) target attainment and risk of toxicity for different combinations of gentamicin regimens (3–7 mg/kg q24h) and CRRT effluent doses (30–50 mL/h/kg) were evaluated by Monte Carlo simulation. The probability of target attainment (PTA) was determined for the PK/PD indices of the ratio of drug peak concentration/minimum inhibitory concentration (Cmax/MIC > 10) and the ratio of area under the drug concentration–time curve/MIC over 24 h (AUC0-24h/MIC > 100), and the risk of toxicity was estimated by drug trough concentration thresholds (1 and 2 mg/L). Results A one-compartment model adequately described the PK characteristics of gentamicin. Covariates including body weight, age, gender, and CRRT modality did not influence the PK parameters of gentamicin based on our dataset. All studied gentamicin regimens failed to achieve satisfactory PTAs for pathogens with an MIC ≥2 mg/L. A good balance of PK/PD target attainment and risk of toxicity (>2 mg/L) was achieved under 7 mg/kg gentamicin q24h and 40 mL/kg/h CRRT dose for an MIC ≤1 mg/L. CRRT dose intensity had a significant impact on the target attainment of AUC0-24h/MIC >100 and risk of toxicity. Conclusion A combination of 7 mg/kg gentamicin q24h and 40 mL/kg/h CRRT dose might be considered as a starting treatment option for CRRT patients, and drug monitoring is required to manage toxicity.
Collapse
Affiliation(s)
- Sha He
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
| | - Zeneng Cheng
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
| | - Feifan Xie
- Division of Biopharmaceutics and Pharmacokinetics, Xiangya School of Pharmaceutical Sciences, Central South University, Changsha, 410013, People's Republic of China
| |
Collapse
|
10
|
Mørk ML, Andersen JT, Lausten-Thomsen U, Gade C. The Blind Spot of Pharmacology: A Scoping Review of Drug Metabolism in Prematurely Born Children. Front Pharmacol 2022; 13:828010. [PMID: 35242037 PMCID: PMC8886150 DOI: 10.3389/fphar.2022.828010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 01/25/2022] [Indexed: 12/30/2022] Open
Abstract
The limit for possible survival after extremely preterm birth has steadily improved and consequently, more premature neonates with increasingly lower gestational age at birth now require care. This specialized care often include intensive pharmacological treatment, yet there is currently insufficient knowledge of gestational age dependent differences in drug metabolism. This potentially puts the preterm neonates at risk of receiving sub-optimal drug doses with a subsequent increased risk of adverse or insufficient drug effects, and often pediatricians are forced to prescribe medication as off-label or even off-science. In this review, we present some of the particularities of drug disposition and metabolism in preterm neonates. We highlight the challenges in pharmacometrics studies on hepatic drug metabolism in preterm and particularly extremely (less than 28 weeks of gestation) preterm neonates by conducting a scoping review of published literature. We find that >40% of included studies failed to report a clear distinction between term and preterm children in the presentation of results making direct interpretation for preterm neonates difficult. We present summarized findings of pharmacokinetic studies done on the major CYP sub-systems, but formal meta analyses were not possible due the overall heterogeneous approaches to measuring the phase I and II pathways metabolism in preterm neonates, often with use of opportunistic sampling. We find this to be a testament to the practical and ethical challenges in measuring pharmacokinetic activity in preterm neonates. The future calls for optimized designs in pharmacometrics studies, including PK/PD modeling-methods and other sample reducing techniques. Future studies should also preferably be a collaboration between neonatologists and clinical pharmacologists.
Collapse
Affiliation(s)
- Mette Louise Mørk
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Jón Trærup Andersen
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Ulrik Lausten-Thomsen
- Department of Neonatology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christina Gade
- Department of Clinical Pharmacology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| |
Collapse
|
11
|
Samb A, Kruizinga M, Tallahi Y, van Esdonk M, van Heel W, Driessen G, Bijleveld Y, Stuurman R, Cohen A, van Kaam A, de Haan TR, Mathôt R. Saliva as a sampling matrix for therapeutic drug monitoring of gentamicin in neonates: A prospective population pharmacokinetic and simulation study. Br J Clin Pharmacol 2021; 88:1845-1855. [PMID: 34625981 PMCID: PMC9298055 DOI: 10.1111/bcp.15105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022] Open
Abstract
Aims Therapeutic drug monitoring (TDM) of gentamicin in neonates is recommended for safe and effective dosing and is currently performed by plasma sampling, which is an invasive and painful procedure. In this study, feasibility of a non‐invasive gentamicin TDM strategy using saliva was investigated. Methods This was a multicentre, prospective, observational cohort study including 54 neonates. Any neonate treated with intravenous gentamicin was eligible for the study. Up to eight saliva samples were collected per patient at different time‐points. Gentamicin levels in saliva were determined with liquid chromatography tandem mass‐spectrometry (LC–MS/MS). A population pharmacokinetic (PK) model was developed using nonlinear mixed‐effects modelling (NONMEM) to describe the relation between gentamicin concentrations in saliva and plasma. Monte Carlo simulations with a representative virtual cohort (n = 3000) were performed to evaluate the probability of target attainment with saliva versus plasma TDM. Results Plasma PK was adequately described with an earlier published model. An additional saliva compartment describing the salivary gentamicin concentrations was appended to the model with first‐order input (k13 0.023 h−1) and first‐order elimination (k30 0.169 h−1). Inter‐individual variability of k30 was 38%. Postmenstrual age (PMA) correlated negatively with both k13 and k30. Simulations demonstrated that TDM with four saliva samples was accurate in 81% of the simulated cases versus 94% when performed with two plasma samples and 87% when performed with one plasma sample. Conclusion TDM of gentamicin using saliva is feasible and the difference in precision between saliva and plasma TDM may not be clinically relevant, especially for premature neonates.
Collapse
Affiliation(s)
- Amadou Samb
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Matthijs Kruizinga
- Centre for Human Drug Research, Leiden, the Netherlands.,Juliana Children's Hospital, HAGA Teaching Hospital, The Hague, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands
| | - Younes Tallahi
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Willemijn van Heel
- Juliana Children's Hospital, HAGA Teaching Hospital, The Hague, the Netherlands
| | - Gertjan Driessen
- Juliana Children's Hospital, HAGA Teaching Hospital, The Hague, the Netherlands.,Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Yuma Bijleveld
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Rik Stuurman
- Centre for Human Drug Research, Leiden, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands
| | - Adam Cohen
- Centre for Human Drug Research, Leiden, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands
| | - Anton van Kaam
- Department of Neonatology, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Timo R de Haan
- Department of Neonatology, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron Mathôt
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
| |
Collapse
|
12
|
Tu Q, Cotta M, Raman S, Graham N, Schlapbach L, Roberts JA. Individualized precision dosing approaches to optimize antimicrobial therapy in pediatric populations. Expert Rev Clin Pharmacol 2021; 14:1383-1399. [PMID: 34313180 DOI: 10.1080/17512433.2021.1961578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction:Severe infections continue to impose a major burden on critically ill children and mortality rates remain stagnant. Outcomes rely on accurate and timely delivery of antimicrobials achieving target concentrations in infected tissue. Yet, developmental aspects, disease-related variables, and host factors may severely alter antimicrobial pharmacokinetics in pediatrics. The emergence of antimicrobial resistance increases the need for improved treatment approaches.Areas covered:This narrative review explores why optimization of antimicrobial therapy in neonates, infants, children, and adolescents is crucial and summarizes the possible dosing approaches to achieve antimicrobial individualization. Finally, we outline a roadmap toward scientific evidence informing the development and implementation of precision antimicrobial dosing in critically ill children.The literature search was conducted on PubMed using the following keywords: neonate, infant, child, adolescent, pediatrics, antimicrobial, pharmacokinetic, pharmacodynamic target, Bayes dosing software, optimizing, individualizing, personalizing, precision dosing, drug monitoring, validation, attainment, and software implementation. Further articles were sought from the references of the above searched articles.Expert opinion:Recently, technological innovations have emerged that enabled the development of individualized antimicrobial dosing approaches in adults. More work is required in pediatrics to make individualized antimicrobial dosing approaches widely operationalized in this population.
Collapse
Affiliation(s)
- Quyen Tu
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Menino Cotta
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sainath Raman
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Centre for Children's Health Research (CCHR), The University of Queensland, Brisbane, QLD, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Luregn Schlapbach
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, The University Children's Hospital Zurich, Switzerland
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| |
Collapse
|
13
|
Kruizinga MD, Stuurman FE, Driessen GJA, Cohen AF, Bergmann KR, van Esdonk MJ. Theoretical Performance of Nonlinear Mixed-Effect Models Incorporating Saliva as an Alternative Sampling Matrix for Therapeutic Drug Monitoring in Pediatrics: A Simulation Study. Ther Drug Monit 2021; 43:546-554. [PMID: 34250966 DOI: 10.1097/ftd.0000000000000904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Historically, pharmacokinetic (PK) studies and therapeutic drug monitoring (TDM) have relied on plasma as a sampling matrix. Noninvasive sampling matrices, such as saliva, can reduce the burden on pediatric patients. The variable plasma-saliva relationship can be quantified using population PK models (nonlinear mixed-effect models). However, criteria regarding acceptable levels of variability in such models remain unclear. In this simulation study, the authors aimed to propose a saliva TDM evaluation framework and evaluate model requirements in the context of TDM, with gentamicin and lamotrigine as model compounds. METHODS Two population pharmacokinetic models for gentamicin in neonates and lamotrigine in pediatrics were extended with a saliva compartment including a delay constant (kSALIVA), a saliva:plasma ratio, and between-subject variability (BSV) on both parameters. Subjects were simulated using a realistic covariate distribution. Bayesian maximum a posteriori TDM was applied to assess the performance of an increasing number of TDM saliva samples and varying levels of BSV and residual variability. Saliva TDM performance was compared with plasma TDM performance. The framework was applied to a known voriconazole saliva model as a case study. RESULTS TDM performed using saliva resulted in higher target attainment than no TDM, and a residual proportional error <25% on saliva observations led to saliva TDM performance comparable with plasma TDM. BSV on kSALIVA did not affect performance, whereas increasing BSV on saliva:plasma ratios by >25% for gentamicin and >50% for lamotrigine reduced performance. The simulated target attainment for voriconazole saliva TDM was >90%. CONCLUSIONS Saliva as an alternative matrix for noninvasive TDM is possible using nonlinear mixed-effect models combined with Bayesian optimization. This article provides a workflow to explore TDM performance for compounds measured in saliva and can be used for evaluation during model building.
Collapse
Affiliation(s)
- Matthijs D Kruizinga
- Centre for Human Drug Research, Leiden
- Juliana Children's Hospital, HAGA Teaching Hospital, the Hague
- Leiden University Medical Centre, Leiden ; and
| | - Frederik E Stuurman
- Centre for Human Drug Research, Leiden
- Leiden University Medical Centre, Leiden ; and
| | - Gertjan J A Driessen
- Juliana Children's Hospital, HAGA Teaching Hospital, the Hague
- Department of Pediatrics, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Adam F Cohen
- Centre for Human Drug Research, Leiden
- Leiden University Medical Centre, Leiden ; and
| | | | | |
Collapse
|
14
|
Anibaletto Dos Santos AL, Cezimbra da Silva AC, de Lima Feltraco Lizot L, Schneider A, Hahn RZ, Meireles YF, Pagnussat LR, Nonnenmacher JL, Hahn SR, Linden R. Sensitive determination of gentamicin in plasma using ion-exchange solid-phase extraction followed by UHPLC-MS/MS analysis. Pract Lab Med 2021; 26:e00246. [PMID: 34337126 PMCID: PMC8318924 DOI: 10.1016/j.plabm.2021.e00246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 06/18/2021] [Accepted: 07/14/2021] [Indexed: 11/27/2022] Open
Abstract
Background Therapeutic drug monitoring (TDM) of gentamicin sulfate (GEN) is usually recommended, particularly in critical patients. Only a few reports had described the determination of GEN in plasma or plasma using LC-MS/MS. Objective This study aimed to develop and validate a sensitive ultra-high-performance liquid chromatography coupled to tandem mass spectrometry (UHPLC-MS/MS) assay for the quantification of GEN in small volumes of human plasma. Results The use of a very low concentration of the ion-pairing agent HFBA allowed significant retention of the very polar GEN forms in a reversed phase UHPLC column. The solid-phase extraction (SPE) procedure allowed clean extracts, with no interferences detected in blank samples, and high sensitivity. The assay was linear on the range of 0.2–40 mg L−1 of GEN complex. The combined GEN complex had inter-assay CV of 8.8–10.0%, intra-assay CV of 10.2–11.0%, and accuracy of 96.8–104.0%. The assay was applied to 17 clinical samples obtained from neonate patients. Measured concentrations were in the range of 0.15–3.57 mg L−1 for GEN C1, 0.12–3.55 mg L−1 for GEN C1a, 0.20–5.77 mg L−1 for GEN C2, and 0.47–12.88 mg L−1 for the GEN complex, all within the linear range of the assay. Conclusion A sensitive assay for the quantification of gentamicin in plasma using anion-exchange SPE and UHPLC-MS/MS was validated. The assay can be used for TDM of gentamicin, particularly in centers with access to proper instrumentation and with a low demand for gentamicin measurements, where immunoassays are not cost-effective. Gentamicin was extracted from plasma using ion-exchange solid phase extraction. Chromatographic conditions were previously applied for amikacin and vancomycin. Gentamicin was measured with acceptable accuracy and precision using UHPLC-MS/MS. The assay was sensitive and had a linear range covering clinically relevant concentrations.
Collapse
Affiliation(s)
- Ana Laura Anibaletto Dos Santos
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil.,Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Brazil
| | - Anne Caroline Cezimbra da Silva
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil.,Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Brazil
| | - Lilian de Lima Feltraco Lizot
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil.,Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Brazil
| | - Anelise Schneider
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Brazil
| | - Roberta Zilles Hahn
- Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Brazil
| | | | | | | | | | - Rafael Linden
- Analytical Toxicology Laboratory, Universidade Feevale, Novo Hamburgo, RS, Brazil.,Graduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Brazil
| |
Collapse
|
15
|
Le J, Greenberg RG, Benjamin DK, Yoo Y, Zimmerman KO, Cohen-Wolkowiez M, Wade KC. Prolonged Post-Discontinuation Antibiotic Exposure in Very Low Birth Weight Neonates at Risk for Early-Onset Sepsis. J Pediatric Infect Dis Soc 2021; 10:615-621. [PMID: 33491088 PMCID: PMC8163059 DOI: 10.1093/jpids/piaa172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/28/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Premature, very low birth weight (VLBW) neonates are at risk for early-onset sepsis and receive ampicillin and gentamicin post-birth. Antimicrobial stewardship supports short-course antibiotics, but how long antibiotic concentrations remain therapeutic post-last dose is unknown. METHODS Using Monte Carlo simulations (NONMEM 7.3), we analyzed antibiotic exposures in a retrospective cohort of 34 689 neonates (<1500 g, 22-27 weeks of gestation). Therapeutic exposure for ampicillin and gentamicin was evaluated relative to the minimum inhibitory concentration (MIC) for common pathogens (MIC 0.25-8 mcg/mL for group B streptococcus [GBS] and Escherichia coli). Post-discontinuation antibiotic exposure (PDAE) was defined as the time from the last dose to time when concentration decreased below MIC. RESULTS Neonates had a median (range) gestational age of 26 (22-27) weeks and BW, 790 g (400-1497) . All ampicillin dosing regimens (50-100 mg/kg every 8-12 hours for 2-6 doses) achieved therapeutic exposures > MIC range. After the last dose, the PDAE mean (95% confidence interval [CI]) ranged from 34 to 50 hours (17-79) for E. coli (MIC 8) and 82 to 104 hours (95% CI: 39-122) for GBS (MIC 0.25); longer PDAE occurred with higher dose, shorter interval, and longer course. Short-course ampicillin (2 doses, 50 mg/kg every 12 hours) provided PDAE 34 hours for E. coli and 82 hours for GBS. Single-dose 5 mg/kg gentamicin provided PDAE > MIC 2 for 26 hours. CONCLUSIONS In VLBW neonates, ampicillin exposure remains therapeutic long after the last dose. Short-course ampicillin provided therapeutic exposures throughout the typical blood culture incubation period.
Collapse
Affiliation(s)
- Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California–San Diego, La Jolla, California, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - YoungJun Yoo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California–San Diego, La Jolla, California, USA
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kelly C Wade
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
16
|
Abduljalil K, Pan X, Pansari A, Jamei M, Johnson TN. A Preterm Physiologically Based Pharmacokinetic Model. Part I: Physiological Parameters and Model Building. Clin Pharmacokinet 2021; 59:485-500. [PMID: 31583613 DOI: 10.1007/s40262-019-00825-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Developmental physiology can alter pharmacotherapy in preterm populations. Because of ethical and clinical constraints in studying this vulnerable age group, physiologically based pharmacokinetic models offer a viable alternative approach to predicting drug pharmacokinetics and pharmacodynamics in this population. However, such models require comprehensive information on the changes of anatomical, physiological and biochemical variables, where such data are not available in a single source. OBJECTIVE The objective of this study was to integrate the relevant physiological parameters required to build a physiologically based pharmacokinetic model for the preterm population. METHODS Published information on developmental preterm physiology and some drug-metabolising enzymes were collated and analysed. Equations were generated to describe the changes in parameter values during growth. RESULTS Data on organ size show different growth patterns that were quantified as functions of bodyweight to retain physiological variability and correlation. Protein binding data were quantified as functions of age as the body weight was not reported in the original articles. Ontogeny functions were derived for cytochrome P450 1A2, 3A4 and 2C9. Tissue composition values and how they change with age are limited. CONCLUSIONS Despite the limitations identified in the availability of some tissue composition values, the data presented in this article provide an integrated resource of system parameters needed for building a preterm physiologically based pharmacokinetic model.
Collapse
Affiliation(s)
- Khaled Abduljalil
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK.
| | - Xian Pan
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Amita Pansari
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Masoud Jamei
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Trevor N Johnson
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| |
Collapse
|
17
|
Preterm Physiologically Based Pharmacokinetic Model. Part II: Applications of the Model to Predict Drug Pharmacokinetics in the Preterm Population. Clin Pharmacokinet 2021; 59:501-518. [PMID: 31587145 DOI: 10.1007/s40262-019-00827-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preterm neonates are usually not part of a traditional drug development programme, however they are frequently administered medicines. Developing modelling and simulation tools, such as physiologically based pharmacokinetic (PBPK) models that incorporate developmental physiology and maturation of drug metabolism, can be used to predict drug exposure in this group of patients, and may help to optimize drug dose adjustment. OBJECTIVE The aim of this study was to assess and verify the predictability of a preterm PBPK model using compounds that undergo diverse renal and/or hepatic clearance based on the knowledge of their disposition in adults. METHODS A PBPK model was developed in the Simcyp Simulator V17 to predict the pharmacokinetics (PK) of drugs in preterm neonates. Drug parameters for alfentanil, midazolam, caffeine, ibuprofen, gentamicin and vancomycin were collated from the literature. Predicted PK parameters and profiles were compared against the observed data. RESULTS The preterm PBPK model predicted the PK changes of the six compounds using ontogeny functions for cytochrome P450 (CYP) 1A2, CYP2C9 and CYP3A4 after oral and intravenous administrations. For gentamicin and vancomycin, the maturation of renal function was able to predict the exposure of these two compounds after intravenous administration. All PK parameter predictions were within a twofold error criteria. CONCLUSION While the developed preterm model for the prediction of PK behaviour in preterm patients is not intended to replace clinical studies, it can potentially help with deciding on first-time dosing in this population and study design in the absence of clinical data.
Collapse
|
18
|
D'Agate S, Musuamba FT, Jacqz-Aigrain E, Della Pasqua O. Simplified Dosing Regimens for Gentamicin in Neonatal Sepsis. Front Pharmacol 2021; 12:624662. [PMID: 33762945 PMCID: PMC7982486 DOI: 10.3389/fphar.2021.624662] [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: 10/31/2020] [Accepted: 01/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background: The effectiveness of antibiotics for the treatment of severe bacterial infections in newborns in resource-limited settings has been determined by empirical evidence. However, such an approach does not warrant optimal exposure to antibiotic agents, which are known to show different disposition characteristics in this population. Here we evaluate the rationale for a simplified regimen of gentamicin taking into account the effect of body size and organ maturation on pharmacokinetics. The analysis is supported by efficacy data from a series of clinical trials in this population. Methods: A previously published pharmacokinetic model was used to simulate gentamicin concentration vs. time profiles in a virtual cohort of neonates. Model predictive performance was assessed by supplementary external validation procedures using therapeutic drug monitoring data collected in neonates and young infants with or without sepsis. Subsequently, clinical trial simulations were performed to characterize the exposure to intra-muscular gentamicin after a q.d. regimen. The selection of a simplified regimen was based on peak and trough drug levels during the course of treatment. Results: In contrast to current World Health Organization guidelines, which recommend gentamicin doses between 5 and 7.5 mg/kg, our analysis shows that gentamicin can be used as a fixed dose regimen according to three weight-bands: 10 mg for patients with body weight <2.5 kg, 16 mg for patients with body weight between 2.5 and 4 kg, and 30 mg for those with body weight >4 kg. Conclusion: The choice of the dose of an antibiotic must be supported by a strong scientific rationale, taking into account the differences in drug disposition in the target patient population. Our analysis reveals that a simplified regimen is feasible and could be used in resource-limited settings for the treatment of sepsis in neonates and young infants with sepsis aged 0–59 days.
Collapse
Affiliation(s)
- S D'Agate
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - F Tshinanu Musuamba
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| | - E Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Centre Hospitalier Universitaire, Hôpital Robert Debré, Paris, France
| | - O Della Pasqua
- Clinical Pharmacology and Therapeutics Group, University College London, London, United Kingdom
| |
Collapse
|
19
|
Salem F, Johnson TN, Hodgkinson ABJ, Ogungbenro K, Rostami‐Hodjegan A. Does "Birth" as an Event Impact Maturation Trajectory of Renal Clearance via Glomerular Filtration? Reexamining Data in Preterm and Full-Term Neonates by Avoiding the Creatinine Bias. J Clin Pharmacol 2020; 61:159-171. [PMID: 32885464 PMCID: PMC7818478 DOI: 10.1002/jcph.1725] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
Glomerular filtration rate (GFR) is an important measure of renal function. Various models for its maturation have recently been compared; however, these have used markers, which are subject to different renal elimination processes. Inulin clearance data (a purer probe of GFR) collected from the literature were used to determine age‐related changes in GFR aspects of renal drug excretion in pediatrics. An ontogeny model was derived using a best‐fit model with various combinations of covariates such as postnatal age, gestational age at birth, and body weight. The model was applied to the prediction of systemic clearance of amikacin, gentamicin, vancomycin, and gadobutrol. During neonatal life, GFR increased as a function of both gestational age at birth and postnatal age, hence implying an impact of birth and a discrepancy in GFR for neonates with the same postmenstrual age depending on gestational age at birth (ie, neonates who were outside the womb longer had higher GFR, on average). The difference in GFR between pre‐term and full‐term neonates with the same postmenstrual age was negligible from beyond 1.25 years. Considering both postnatal age and gestational age at birth in GFR ontogeny models is important because postmenstrual age alone ignores the impact of birth. Most GFR models use covariates of body size in addition to age. Therefore, prediction from these models will also depend on the change in anthropometric characteristics with age. The latter may not be similar in various ethnic groups, and this makes the head‐to‐head comparison of models very challenging.
Collapse
Affiliation(s)
| | | | | | - Kayode Ogungbenro
- Centre for Applied Pharmacokinetic ResearchDivision of Pharmacy and OptometrySchool of Health SciencesFaculty of BiologyMedicine and HealthManchester Academic Health Science CentreUniversity of ManchesterManchesterUK
| | - Amin Rostami‐Hodjegan
- Certara UK Ltd, Simcyp DivisionSheffieldUK
- Centre for Applied Pharmacokinetic ResearchDivision of Pharmacy and OptometrySchool of Health SciencesFaculty of BiologyMedicine and HealthManchester Academic Health Science CentreUniversity of ManchesterManchesterUK
| |
Collapse
|
20
|
Population pharmacokinetics of gentamicin in haemodialysis patients: modelling, simulations and recommendations. Eur J Clin Pharmacol 2020; 76:947-955. [DOI: 10.1007/s00228-020-02867-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/26/2020] [Indexed: 10/24/2022]
|
21
|
Simulated Comparison of a Bayesian Clinical Decision Support System Versus Standard of Care For Achieving Gentamicin Pharmacokinetic Targets in Neonates. Pediatr Infect Dis J 2020; 39:313-317. [PMID: 32032171 PMCID: PMC7182238 DOI: 10.1097/inf.0000000000002592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gentamicin therapy in neonates is optimized through achieving specific peak and trough concentrations. The objective of this study was to compare the ability a Bayesian clinical decision support system (CDSS) with standard of care (SOC) in determining personalized gentamicin therapies for neonates, at regimen initiation and in response to measured drug concentrations. METHODS This retrospective review and simulation compared target attainment among 4 arms: historical dosing according to SOC, via nomogram for initial dosing (SOC-initial) and via clinician judgment in response to measured concentrations (SOC-adjusted), and simulated dosing using the CDSS, incorporating a neonatal pharmacokinetic model for initial dosing (CDSS-initial) and incorporating maximum a posteriori-Bayesian analysis in response to measured concentrations (CDSS-adjusted). "True" patient pharmacokinetic parameters and peak and trough concentration predictions were calculated via the CDSS using the entirety of the patient dosing and concentration history. The primary outcome was pharmacokinetic target attainment of desired gentamicin peak and trough concentrations. RESULTS The study included 564 gentamicin concentrations among 339 patients. Mean demographics were 35 weeks gestational age (52% premature births) and 2.44 kg dosing weight. Mean PK parameters were 0.0533 L/h/kg clearance, 0.458 L/kg volume of distribution, and 8.66 hours half-life. Peak concentrations in the desired range were achieved in 96% of significantly more often in the CDSS-initial regimens and 94% of CDSS-adjusted regimens versus 86% of SOC-initial regimens and 66% of SOC-adjusted regimens. No difference was found in trough target attainment among study groups. CONCLUSIONS In simulation, a Bayesian CDSS showed superiority to SOC in achieving gentamicin pharmacokinetic exposure targets in neonates. Use of a CDSS may improve the safety and efficacy of gentamicin therapy for neonates.
Collapse
|
22
|
Bergenwall M, Walker SAN, Elligsen M, Iaboni DC, Findlater C, Seto W, Ng E. Optimizing gentamicin conventional and extended interval dosing in neonates using Monte Carlo simulation - a retrospective study. BMC Pediatr 2019; 19:318. [PMID: 31492162 PMCID: PMC6729057 DOI: 10.1186/s12887-019-1676-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although aminoglycosides are routinely used in neonates, controversy exists regarding empiric dosing regimens. The objectives were to determine gentamicin pharmacokinetics in neonates, and develop initial mg/kg dosing recommendations that optimized target peak and trough concentration attainment for conventional and extended-interval dosing (EID) regimens. METHODS Patient demographics and steady-state gentamicin concentration data were retrospectively collected for 60 neonates with no renal impairment admitted to a level III neonatal intensive care unit. Mean pharmacokinetics were calculated and multiple linear regression was performed to determine significant covariates of clearance (L/h) and volume of distribution (L). Classification and regression tree (CART) analysis identified breakpoints for significant covariates. Monte Carlo Simulation (MCS) was used to determine optimal dosing recommendations for each CART-identified sub-group. RESULTS Gentamicin clearance and volume of distribution were significantly associated with weight at gentamicin initiation. CART-identified breakpoints for weight at gentamicin initiation were: ≤ 850 g, 851-1200 g, and > 1200 g. MCS identified that a conventional dose of gentamicin 3.5 mg/kg given every 48 h or an EID of 8-9 mg/kg administered every 72 h in neonates weighing ≤ 850 g, and every 24 and 48 h, respectively, in neonates weighing 851-1200 g, provided the best probability of attaining conventional (peak: 5-10 mg/L and trough: ≤ 2 mg/L) and EID targets (peak:12-20 mg/L, trough:≤ 0.5 mg/L). Insufficient sample size in the > 1200 g neonatal group precluded further investigation of this weight category. CONCLUSIONS This study provides initial gentamicin dosing recommendations that optimize target attainment for conventional and EID regimens in neonates weighing ≤ 1200 g. Prospective validation and empiric dose optimization for neonates > 1200 g is needed.
Collapse
Affiliation(s)
- Monique Bergenwall
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Present Address: Grandview Medical Centre Family Health Team, 167 Hespeler Rd, Cambridge, ON N1R 3H7 Canada
| | - Sandra A. N. Walker
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Sunnybrook Health Sciences Centre Research Institute, Toronto, ON Canada
| | - Marion Elligsen
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, E-302, Toronto, ON M4N 3M5 Canada
| | - Dolores C. Iaboni
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Carla Findlater
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
| | - Winnie Seto
- Leslie L. Dan Faculty of Pharmacy, University of Toronto, Toronto, ON Canada
- Department of Pharmacy, Hospital for Sick Children, Toronto, ON Canada
| | - Eugene Ng
- Women and Babies Program, Sunnybrook Health Sciences Centre, Toronto, ON Canada
- Department of Paediatrics, University of Toronto, Toronto, ON Canada
| |
Collapse
|
23
|
Wang H, Sherwin C, Gobburu JVS, Ivaturi V. Population Pharmacokinetic Modeling of Gentamicin in Pediatrics. J Clin Pharmacol 2019; 59:1584-1596. [PMID: 31286535 DOI: 10.1002/jcph.1479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/11/2019] [Indexed: 01/16/2023]
Abstract
The primary objective of this work was to characterize the pharmacokinetics (PK) of gentamicin across the whole pediatric age spectrum from premature neonates to young adults with a single model by identifying significant clinical predictors. A nonlinear mixed-effect population PK model was developed with retrospective therapeutic drug-monitoring data. A total of 6459 drug concentration measurements from 3370 hospitalized patients were collected for model building (n = 2357) and evaluation (n = 1013). In agreement with previously reported models, a 2-compartment model with first-order elimination best described the drug PK. Patient-specific factors significantly impacting gentamicin clearance included fat-free mass, postmenstrual age, and serum creatinine (SCr). Based on our model, the deviation of the individual SCr from the age-dependent expected mean SCr value (SCrM) can result in a 40% lower clearance in a patient with renal impairment than that in a patient with normal kidney function, with SCrM:SCr ratios between 0.16 and 3.2 in this study. Consistent with the known age-dependent changes of the proportion of extracellular water in body weight, the inclusion of the impact of extracellular water maturation on the central volume of distribution was found to improve the model fitting significantly. In comparison with other published models, model evaluation suggested the developed model was the least biased and physiologically most representative. These results will be used to inform individualized initial dosing strategies and serve as a prior PK model for Bayesian updating and forecasting as individual clinical observations become available.
Collapse
Affiliation(s)
- Hechuan Wang
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Catherine Sherwin
- Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Jogarao V S Gobburu
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Vijay Ivaturi
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| |
Collapse
|
24
|
Abstract
Antimicrobial medications are the most commonly used medications in the neonatal intensive care unit. Antibiotics are used for infection prophylaxis, empiric treatment, and definitive treatment of confirmed infection. The choice of medication should be informed by the epidemiology and microbiology of infection in specific clinical scenarios and by the clinical condition of the infant. Understanding evolving pathogen susceptibility to antimicrobials and key pharmacotherapy determinants in neonates can inform optimal antibiotic use.
Collapse
Affiliation(s)
- Sagori Mukhopadhyay
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Kelly C Wade
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Karen M Puopolo
- Section on Newborn Medicine, Pennsylvania Hospital, Philadelphia, PA, USA; Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; CHOP Newborn Care, Pennsylvania Hospital, 800 Spruce Street, Philadelphia, PA 19107, USA.
| |
Collapse
|
25
|
Abstract
Pharmacometrics have advanced from compartmental analysis to noncompartmental analysis and population pharmacokinetics that require complicated mathematical programs. These sophisticated mathematical analyses determine not only the usual pharmacometric measures of clearance and volume of distribution but also the effects of covariates on these measures. Although these analyses are very suitable to studies of small patient populations often encountered in pediatric studies, most pediatric clinicians have not been trained in how these analyses are conducted or the meaning of the results of these analyses expressed in terms of error measures and fixed and variable effects. In addition, clinicians may not be able to evaluate whether their patient population is adequately represented in the analysis. Thorough and clear descriptions of the methodology and the strengths and weaknesses of these analyses need to be published in journals read by clinicians.
Collapse
Affiliation(s)
- Xiaoxi Liu
- 1 Department of Pediatrics, Division of Clinical Pharmacology, University of Utah, Salt Lake City, UT, USA
| | - Robert M Ward
- 1 Department of Pediatrics, Division of Clinical Pharmacology, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
26
|
Crcek M, Zdovc J, Kerec Kos M. A review of population pharmacokinetic models of gentamicin in paediatric patients. J Clin Pharm Ther 2019; 44:659-674. [PMID: 31102287 DOI: 10.1111/jcpt.12850] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/18/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Gentamicin is often used for the treatment of Gram-negative infections. Due to pharmacokinetic variability in paediatric patients, appropriate dosing of gentamicin in the paediatric population is challenging. This article reviews published population pharmacokinetic models of gentamicin in paediatric patients, identifies covariates that significantly influence gentamicin pharmacokinetics, and determines whether there is a consensus on proposed dosing for intravenous gentamicin in this population. METHODS The PubMed database was searched for articles published until the end of 2017. If the articles described population pharmacokinetic models of gentamicin in the paediatric population (after intravenous administration of gentamicin), the following data were extracted: type of study, year of publication, population characteristics and number of patients, gentamicin dosing, total number of gentamicin (serum and/or plasma) concentrations, type of population modelling approach, developed model with pharmacokinetic parameters and covariates included. RESULTS AND DISCUSSION In most of the studies, one- or two-compartment modelling was applied. The mean estimated gentamicin clearance for newborns, infants and the complete paediatric population was 0.048, 0.13 and 0.067 L/h/kg, respectively, and the mean predicted volume of distribution was 0.475, 0.35 and 0.33 L/kg, respectively. The values reflect differences in body composition and kidney maturation within the different paediatric populations. Gentamicin pharmacokinetics were most influenced by age, body size and renal function. WHAT IS NEW AND CONCLUSION Based on our review, the authors agree on a prolonged dosing interval for preterm and term newborns (up to 48 hours). However, there was no agreement on proposed dosing with respect to gestational age. In general, the proposed daily doses were lower compared to those initially applied for preterm newborns and comparable to those for term newborns. For infants and children, the dosing interval remained unchanged (24 hours), but the proposed daily doses were higher than actually applied. When differences in the paediatric population are considered and an appropriate population PK model with applicable covariates is applied, dosing can be individualized. In the future, studies of gentamicin pharmacokinetics in paediatric patients should focus on currently underestimated covariates, such as fat-free mass, concomitantly administered drugs, body temperature and critical illness because these can change gentamicin PK considerably. Consequently, different dosing is required and TDM becomes even more important.
Collapse
Affiliation(s)
- Mateja Crcek
- University of Ljubljana, Faculty of Pharmacy, Department of Biopharmaceutics and Pharmacokinetics, Ljubljana, Slovenia
| | - Jurij Zdovc
- University of Ljubljana, Faculty of Pharmacy, Department of Biopharmaceutics and Pharmacokinetics, Ljubljana, Slovenia
| | - Mojca Kerec Kos
- University of Ljubljana, Faculty of Pharmacy, Department of Biopharmaceutics and Pharmacokinetics, Ljubljana, Slovenia
| |
Collapse
|
27
|
Hurkacz M, Monika Nowakowska J, Paluszyńska D, Królak-Olejnik B. Individualization of treatment with gentamicin in neonates based on drug concentration in the blood serum. DEVELOPMENTAL PERIOD MEDICINE 2019. [PMID: 30954977 PMCID: PMC8522342 DOI: 10.34763/devperiodmed.20192301.2127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Aim: To evaluate how useful it is to make measurements of gentamicin concentrations in newborns' blood in order to optimize antibiotic therapy. PATIENTS AND METHODS Material and methods: 73 newborns empirically treated with gentamicin, in doses consistent with the Neofax® guidelines. There were 152 measurements of maximum and minimum serum gentamicin concentrations. Samples were determined based on the chemiluminescence technique on the Siemens Advia Centaur analyzer. The concentrations of gentamicin that were measured were compared with various therapeutic ranges used in the literature. RESULTS Results: According to the standards adopted in the University Hospital in Wrocław, the maximum concentration was reached in 38.16% of all the children, while the minimum in 26.32%. In other children the concentrations were below or above the therapeutic range. According to the Neofax® guidelines, the intended maximum concentration was observed in 71.05% of the newborns, and the minimum in 32.89%. The minimum concentration of <2 mg/L was found in 93.42% of the newborns, while >2 mg/L was determined in 33.33%, despite a 48-hour dosing interval. These were premature babies (<28th week of gestational age) and 55.56% of them reached a maximum concentration of 5-12 mg/L. There was no significant correlation between maximum or minimum concentration and gestational age or body weight. CONCLUSION Conclusions: 1. The dosage of gentamicin in newborns according to the Neofax® recommendations does not ensure achieving the intended serum antibiotic concentrations. 2. In order to optimize gentamicin therapy in newborns it is necessary to individualize the dose based on measurements of drug concentrations in the blood and pharmacokinetic calculations.
Collapse
Affiliation(s)
- Magdalena Hurkacz
- Department of Clinical Pharmacology, Wrocław Medical University, Wrocław, Poland,Magdalena Hurkacz Department of Clinical Pharmacology, Wrocław Medical University Borowska Str. 211, 50-556 Wrocław, Poland phone 601790166
| | | | - Dorota Paluszyńska
- Department and Clinic of Neonatology, Wrocław Medical University, Wrocław, Poland
| | | |
Collapse
|
28
|
Litz JE, Goedicke-Fritz S, Härtel C, Zemlin M, Simon A. Management of early- and late-onset sepsis: results from a survey in 80 German NICUs. Infection 2019; 47:557-564. [DOI: 10.1007/s15010-018-1263-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/18/2018] [Indexed: 12/16/2022]
|
29
|
Puia-Dumitrescu M, Bretzius OM, Brown N, Fitz-Henley JA, Ssengonzi R, Wechsler CS, Gray KD, Benjamin DK, Smith PB, Clark RH, Gonzalez D, Hornik CP. Evaluation of Gentamicin Exposure in the Neonatal Intensive Care Unit and Hearing Function at Discharge. J Pediatr 2018; 203:131-136. [PMID: 30244991 PMCID: PMC6361629 DOI: 10.1016/j.jpeds.2018.07.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/25/2018] [Accepted: 07/30/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To characterize the association between gentamicin dosing, duration of treatment, and ototoxicity in hospitalized infants. STUDY DESIGN This retrospective cohort study conducted at 330 neonatal intensive care units (2002-2014) included inborn infants exposed to gentamicin with available hearing screen results, and excluded infants with incomplete dosing data and major congenital anomalies. Our primary outcome was the final hearing screen result performed during hospitalization: abnormal (failed or referred for further testing in one or both ears) or normal (bilateral passed). The 4 measures of gentamicin exposure were highest daily dose, average daily dose, cumulative dose, and cumulative duration of exposure. We fitted separate multivariable logistic regression models adjusted for demographics, comorbidities, and other clinical events. RESULTS A total of 84 808 infants met inclusion/exclusion criteria; median (25th, 75th percentile) gestational age and birth weight were 35 weeks (33, 38) and 2480 g (1890, 3184), respectively. Failed hearing screens occurred in 3238 (3.8%) infants; failed screens were more likely in infants of lower gestational age and birth weight, who had longer hospital lengths of stay, higher rates of morbidities, and were small for gestational age. Median highest daily dose, average daily dose, and cumulative dose were 4.0 mg/kg/day (3.0, 4.0), 3.8 mg/kg/day (3.0, 4.0), and 12.1 mg/kg (9.1, 20.5), respectively. Median cumulative duration of exposure was 3 days (3, 6). In adjusted analysis, gentamicin dose and duration of therapy were not associated with hearing screen failure. CONCLUSIONS Gentamicin dosing and duration of treatment were not associated with increased odds of failed hearing screen at the time of discharge from initial neonatal intensive care unit stay.
Collapse
Affiliation(s)
- Mihai Puia-Dumitrescu
- Department of Pediatrics, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | - Nia Brown
- Duke Clinical Research Institute, Durham, NC
| | | | | | | | - Keyaria D Gray
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | | | - P Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Daniel Gonzalez
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Christoph P Hornik
- Department of Pediatrics, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| |
Collapse
|
30
|
Ge S, Beechinor RJ, Hornik CP, Standing JF, Zimmerman K, Cohen-Wolkowiez M, Laughon MM, Clark R, Gonzalez D. External Evaluation of a Gentamicin Infant Population Pharmacokinetic Model Using Data from a National Electronic Health Record Database. Antimicrob Agents Chemother 2018; 62:e00669-18. [PMID: 29914947 PMCID: PMC6125537 DOI: 10.1128/aac.00669-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/08/2018] [Indexed: 11/20/2022] Open
Abstract
Gentamicin is a common antibiotic used in neonates and infants. A recently published population pharmacokinetic (PK) model was developed using data from multiple studies, and the objective of our analyses was to evaluate the feasibility of using a national electronic health record (EHR) database for further external evaluation of this model. Our results suggest that, with proper data capture procedures, EHR data can serve as a potential data source for external evaluation of PK models.
Collapse
Affiliation(s)
- Shufan Ge
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ryan J Beechinor
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joseph F Standing
- Inflammation, Infection, and Rheumatology Section, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Kanecia Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Reese Clark
- Pediatrix Medical Group, Inc., Sunrise, Florida
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| |
Collapse
|
31
|
Tenaglia E, Ferretti A, Decosterd LA, Werner D, Mercier T, Widmer N, Buclin T, Guiducci C. Comparison against current standards of a DNA aptamer for the label-free quantification of tobramycin in human sera employed for therapeutic drug monitoring. J Pharm Biomed Anal 2018; 159:341-347. [PMID: 30025299 DOI: 10.1016/j.jpba.2018.06.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/14/2018] [Accepted: 06/29/2018] [Indexed: 12/28/2022]
Abstract
The use of DNA aptamers in biosensors for the quantification of pharmaceuticals in the clinics would help to overcome the limitations of antibody-based detection for small molecules. The interest for such systems is proven by the ever-increasing number of aptamer-based solutions for analytics proposed in the literature as proof-of-concept demonstrators. Despite such diversity, these platforms often lack a comparative assessment of their performances against the current standard of practice in the clinics when using real samples. We employed an aptamer against tobramycin discovered in our laboratory to quantify through surface plasmon resonance the concentration of the antibiotic in clinical samples obtained from patients treated with tobramycin and undergoing therapeutic drug monitoring. We then compared the performances of our detection strategy against the current standard of practice. Our results show how, using adequate calibration and matrix complexity reduction, DNA aptamer-based direct assays can assess clinically relevant concentrations of small molecules in patient serum and with good correlation to current standards used in the clinics.
Collapse
Affiliation(s)
- Enrico Tenaglia
- Ecole Polytechnique Fédérale de Lausanne, Institute of Bioengineering, Station 17, CH-1015 Lausanne, Switzerland
| | - Anna Ferretti
- Ecole Polytechnique Fédérale de Lausanne, Institute of Bioengineering, Station 17, CH-1015 Lausanne, Switzerland
| | - Laurent A Decosterd
- Laboratory of Clinical Pharmacology, Service of Clinical Pharmacology, Lausanne University Hospital, Lausanne, Switzerland
| | - Dominique Werner
- Clinical Chemistry Laboratory, Lausanne University Hospital, Lausanne, Switzerland
| | - Thomas Mercier
- Laboratory of Clinical Pharmacology, Service of Clinical Pharmacology, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Widmer
- Service of Clinical Pharmacology, Lausanne University Hospital, Lausanne, Switzerland; Pharmacy of Eastern Vaud Hospitals, Vevey, Switzerland
| | - Thierry Buclin
- Service of Clinical Pharmacology, Lausanne University Hospital, Lausanne, Switzerland
| | - Carlotta Guiducci
- Ecole Polytechnique Fédérale de Lausanne, Institute of Bioengineering, Station 17, CH-1015 Lausanne, Switzerland.
| |
Collapse
|
32
|
Choi DW, Park JH, Lee SY, An SH. Effect of hypothermia treatment on gentamicin pharmacokinetics in neonates with hypoxic-ischaemic encephalopathy: A systematic review and meta-analysis. J Clin Pharm Ther 2018; 43:484-492. [PMID: 29781085 DOI: 10.1111/jcpt.12711] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Accepted: 04/16/2018] [Indexed: 12/22/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Hypothermia is the current standard therapy for asphyxiated neonates with hypoxic-ischaemic encephalopathy (HIE). Gentamicin is used for the empirical treatment of early-onset neonatal sepsis. We investigated the influence of hypothermia treatment on gentamicin pharmacokinetics and suggested the appropriate dosing recommendations for gentamicin in neonates with HIE receiving hypothermia treatment. METHODS We searched studies published until February 2017 in MEDLINE using PubMed, EMBASE and the Cochrane Library. Three independent reviewers screened the literature and extracted data from each study. All of the studies that reported the blood concentrations or pharmacokinetic parameters of gentamicin in hypothermic neonates with HIE were included in this review. Articles were excluded if they were not original research. RESULT AND DISCUSSION A total of 8 observational studies met the inclusion criteria. Meta-analyses were performed in which the mean difference of gentamicin for the trough concentration and clearance between hypothermic and normothermic neonates were 0.81 mg/L (95% confidence interval [-0.07, 1.69]) and -0.21 mL/kg/min (95% confidence interval [-0.31, -0.12]), respectively. The factors affecting gentamicin clearance in hypothermic neonates with HIE were gestational age, birthweight and serum creatinine. WHAT IS NEW AND CONCLUSION Gentamicin clearance is decreased in neonates with HIE receiving hypothermia treatment compared to those not receiving hypothermia treatment. Modified gentamicin dosing regimens are required to avoid potential toxicity related to higher concentrations during hypothermia treatment.
Collapse
Affiliation(s)
- D W Choi
- College of Pharmacy, Wonkwang University, Iksan, Korea
| | - J H Park
- College of Pharmacy, Wonkwang University, Iksan, Korea
| | - S Y Lee
- College of Pharmacy, Wonkwang University, Iksan, Korea
| | - S H An
- College of Pharmacy, Wonkwang University, Iksan, Korea
| |
Collapse
|
33
|
van Donge T, Pfister M, Bielicki J, Csajka C, Rodieux F, van den Anker J, Fuchs A. Quantitative Analysis of Gentamicin Exposure in Neonates and Infants Calls into Question Its Current Dosing Recommendations. Antimicrob Agents Chemother 2018; 62:e02004-17. [PMID: 29358294 PMCID: PMC5913996 DOI: 10.1128/aac.02004-17] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/09/2018] [Indexed: 12/20/2022] Open
Abstract
Optimal dosing of gentamicin in neonates is still a matter of debate despite its common use. We identified gentamicin dosing regimens from eight international guidelines and seven Swiss neonatal intensive care units. The dose per administration, the dosing interval, the total daily dose, and the demographic characteristics between guidelines were compared. There was considerable variability with respect to dose (4 to 6 mg/kg), dosing interval (24 h to 48 h), total daily dose (2.5 to 6 mg/kg/day), and patient demographic characteristics that were used to calculate individualized dosing regimens. A model-based simulation study in 1071 neonates was performed to determine the achievement of efficacious peak gentamicin concentrations according to predefined MICs (Cmax/MIC ≥ 10) and safe trough concentrations (Cmin ≤ 2 mg/liter) with recommended dosing regimens. MIC targets of 0.5 and 1 mg/liter were used. Dosing optimization was performed giving priority to the first day of treatment and with the goal of simplifying dosing. Current gentamicin neonatal guidelines allow to achieve effective peak concentrations for MICs ≤ 0.5 mg/liter but not higher. Model-based simulations indicate that to attain peak gentamicin concentrations of ≥10 mg/liter, a dose of 7.5 mg/kg should be administered using an extended dosing interval regimen. Trough concentrations of ≤2 mg/liter can be maintained with a dosing interval of 36 to 48 h in neonates according to gestational and postnatal age. For treatment beyond 3 days, therapeutic drug monitoring is advised to maintain adequate serum concentrations.
Collapse
Affiliation(s)
- Tamara van Donge
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Pfister
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Quantitative Solutions, a Certara Company, London, United Kingdom
| | - Julia Bielicki
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Chantal Csajka
- Service of Clinical Pharmacology, Department of Laboratory, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Frederique Rodieux
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - John van den Anker
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Aline Fuchs
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
| |
Collapse
|
34
|
Liem TBY, Slob EMA, Termote JUM, Wolfs TFW, Egberts ACG, Rademaker CMA. Comparison of antibiotic dosing recommendations for neonatal sepsis from established reference sources. Int J Clin Pharm 2018; 40:436-443. [PMID: 29340851 PMCID: PMC5918525 DOI: 10.1007/s11096-018-0589-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 01/04/2018] [Indexed: 11/28/2022]
Abstract
Background Incorrect dosing is the most frequent prescribing error in neonatology, with antibiotics being the most frequently prescribed medicines. Computer physician order entry and clinical decision support systems can create consistency contributing to a reduction of medication errors. Although evidence-based dosing recommendations should be included in such systems, the evidence is not always available and subsequently, dosing recommendations mentioned in guidelines and textbooks are often based on expert opinion. Objective To compare dosage recommendations for antibiotics in neonates with sepsis provided by eight commonly used and well-established international reference sources. Setting An expert team from our Dutch tertiary care neonatal intensive care unit selected eight well-established international reference sources. Method Daily doses of the seven most frequently used antibiotics in the treatment of neonatal sepsis, classified by categories for birth weight and gestational age, were identified from eight well-respected reference sources in neonatology/pediatric infectious diseases. Main outcome measure Standardized average daily dosage. Results A substantial variation in dosage recommendations of antibiotics for neonatal sepsis between the reference sources was shown. Dosage recommendations of ampicillin, ceftazidime, meropenem and vancomycin varied more than recommendations for benzylpenicillin, cefotaxime and gentamicin. One reference source showed a larger variation in dosage recommendations in comparison to the average recommended daily dosage, compared to the other reference sources. Conclusion Antibiotic dosage recommendations for neonates with sepsis can be derived from important reference sources and guidelines. Further exploration to overcome variation in dosage recommendations is necessary to obtain standardized dosage regimens.
Collapse
Affiliation(s)
- T B Y Liem
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands.
| | - E M A Slob
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - J U M Termote
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Centre, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - T F W Wolfs
- Department of Pediatrics, Infectious Diseases and Immunology, Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| | - A C G Egberts
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG, Utrecht, The Netherlands
| | - C M A Rademaker
- Department of Clinical Pharmacy, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Lundlaan 6, 3584 EA, Utrecht, The Netherlands
| |
Collapse
|
35
|
Llanos-Paez CC, Hennig S, Staatz CE. Population pharmacokinetic modelling, Monte Carlo simulation and semi-mechanistic pharmacodynamic modelling as tools to personalize gentamicin therapy. J Antimicrob Chemother 2017; 72:639-667. [PMID: 28062683 DOI: 10.1093/jac/dkw461] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Population pharmacokinetic modelling, Monte Carlo simulation and semi-mechanistic pharmacodynamic modelling are all tools that can be applied to personalize gentamicin therapy. This review summarizes and evaluates literature knowledge on the population pharmacokinetics and pharmacodynamics of gentamicin and identifies areas where further research is required to successfully individualize gentamicin therapy using modelling and simulation techniques. Thirty-five studies have developed a population pharmacokinetic model of gentamicin and 15 studies have made dosing recommendations based on Monte Carlo simulation. Variability in gentamicin clearance was most commonly related to renal function in adults and body weight and age in paediatrics. Nine studies have related aminoglycoside exposure indices to clinical outcomes. Most commonly, efficacy has been linked to a Cmax/MIC ≥7-10 and a AUC24/MIC ≥70-100. No study to date has shown a relationship between predicted achievement of exposure targets and actual clinical success. Five studies have developed a semi-mechanistic pharmacokinetic/pharmacodynamic model to predict bacteria killing and regrowth following gentamicin exposure and one study has developed a deterministic model of aminoglycoside nephrotoxicity. More complex semi-mechanistic models are required that consider the immune response, use of multiple antibiotics, the severity of illness, and both efficacy and toxicity. As our understanding grows, dosing of gentamicin based on sound pharmacokinetic/pharmacodynamic principles should be applied more commonly in clinical practice.
Collapse
|
36
|
Rivera-Chaparro ND, Cohen-Wolkowiez M, Greenberg RG. Dosing antibiotics in neonates: review of the pharmacokinetic data. Future Microbiol 2017; 12:1001-1016. [PMID: 28758800 PMCID: PMC5627030 DOI: 10.2217/fmb-2017-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/23/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are often used in neonates despite the absence of relevant dosing information in drug labels. For neonatal dosing, clinicians must extrapolate data from studies for adults and older children, who have strikingly different physiologies. As a result, dosing extrapolation can lead to increased toxicity or efficacy failures in neonates. Driven by these differences and recent legislation mandating the study of drugs in children and neonates, an increasing number of pharmacokinetic studies of antibiotics are being performed in neonates. These studies have led to new dosing recommendations with particular consideration for neonate body size and maturation. Herein, we highlight the available pharmacokinetic data for commonly used systemic antibiotics in neonates.
Collapse
Affiliation(s)
- Nazario D Rivera-Chaparro
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| |
Collapse
|
37
|
Sohn JA, Kim HS, Oh J, Cho JY, Yu KS, Lee J, Shin SH, Lee JA, Choi CW, Kim EK, Kim BI, Park EA. Prediction of serum theophylline concentrations and cytochrome P450 1A2 activity by analyzing urinary metabolites in preterm infants. Br J Clin Pharmacol 2017; 83:1279-1286. [PMID: 27995649 DOI: 10.1111/bcp.13211] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/08/2016] [Accepted: 12/12/2016] [Indexed: 01/17/2023] Open
Abstract
AIMS The purpose of this study was to explore clinical markers reflecting developmental changes in drug clearance by preterm infants. METHODS Preterm infants administered aminophylline or theophylline to treat apnoea of prematurity were enrolled in this study. Trough and one of 2 h, 4 h or 6 h post-dose blood samples and urine samples were collected during steady state, to determine the concentrations of theophylline and its targeted metabolites. CYP1A2*1C and CYP1A2*1F genotypes were analyzed. Total, renal and nonrenal clearances of theophylline were calculated, and cytochrome P450 1A2 (CYP1A2) activity was obtained from the ratio of 1-methyluric acid and 3-methylxanthine to theophylline in urine. Multiple linear regression analysis was performed to evaluate the relationships between theophylline clearance and the clinical characteristics of preterm infants. RESULTS A total of 152 samples from 104 preterm infants were analyzed. A strong association between the serum trough and urine theophylline concentrations was found (P < 0.001). Total, renal and nonrenal clearances of theophylline were 0.50 ± 0.29 ml kg-1 min-1 , 0.16 ± 0.06 ml kg-1 min-1 and 0.34 ± 0.28 ml kg-1 min-1 , respectively. CYP1A2 activity correlated positively with the postnatal age and postmenstrual age. However, CYP1A2 genotype was not associated with CYP1A2 activity, which was significantly associated with nonrenal clearance. CYP1A2 activity, postnatal age , weight and 24-h urine output were significantly associated with total theophylline clearance. CONCLUSIONS CYP1A2 activity can be monitored using noninvasive random urine samples, and it can be used to assess developmental changes in theophylline clearance by preterm infants.
Collapse
Affiliation(s)
- Jin A Sohn
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Jaeseong Oh
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Joo-Youn Cho
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, South Korea
| | - Juyoung Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin A Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Eun Ae Park
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, South Korea
| |
Collapse
|
38
|
Population Pharmacokinetics and Dosing Considerations for Gentamicin in Newborns with Suspected or Proven Sepsis Caused by Gram-Negative Bacteria. Antimicrob Agents Chemother 2016; 61:AAC.01304-16. [PMID: 27795373 DOI: 10.1128/aac.01304-16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/09/2016] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to describe the population pharmacokinetics (PK) of gentamicin in neonates with suspected or proven Gram-negative sepsis and determine the optimal dosage regimen in relation to the bacterial MICs found in this population. Data were prospectively collected between October 2012 and January 2013 in the Neonatal Intensive Care Unit (NICU) at the Academic Medical Center (AMC), Amsterdam, The Netherlands. A single nonlinear mixed-effects regression analysis (NONMEM) was performed to describe the population PK of gentamicin. Dosage regimens based upon gestational age (GA) were generated using Monte Carlo simulations with the final model. Target values were based on the MIC distribution in our patient population. In total, 136 gentamicin concentrations from 65 (pre)term neonates were included. The PK was best described by an allometric 2-compartment model with postmenstrual age (PMA) as a covariate on clearance (Cl). The MIC distribution (median, 0.75 [range, 0.5 to 1.5] mg/liter) justified a gentamicin target peak concentration of 8 to 12 mg/liter. This study describes the PK of gentamicin in (pre)term neonates. Dosage regimens of 5 mg/kg of body weight every 48 h, 5 mg/kg every 36 h, and 5 mg/kg every 24 h for patients with GAs of <37 weeks, 37 to 40 weeks, and ≥40 weeks, respectively, are recommended.
Collapse
|
39
|
Rao SC, Srinivasjois R, Moon K. One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates. Cochrane Database Syst Rev 2016; 12:CD005091. [PMID: 27921299 PMCID: PMC6464017 DOI: 10.1002/14651858.cd005091.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Animal studies and trials in older children and adults suggest that a 'one dose per day' regimen of gentamicin is superior to a 'multiple doses per day' regimen. OBJECTIVES To compare the efficacy and safety of one dose per day compared to multiple doses per day of gentamicin in suspected or proven sepsis in neonates. SEARCH METHODS Eligible studies were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3) in the Cochrane Library (searched 8 April 2016), MEDLINE (1966 to 8 April 2016), Embase (1980 to 8 April 2016), and CINAHL (December 1982 to 8 April 2016). SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing one dose per day ('once a day') compared to multiple doses per day ('multiple doses a day') of gentamicin to newborn infants. DATA COLLECTION AND ANALYSIS Data collection and analysis was performed according to the standards of the Cochrane Neonatal Review Group. MAIN RESULTS Eleven RCTs were included (N = 574) and 28 excluded. All except one study enrolled infants of more than 32 weeks' gestation. Limited information suggested that infants in both 'once a day' as well as 'multiple doses a day' regimens showed adequate clearance of sepsis (typical RR 1.00, 95% CI 0.84 to 1.19; typical RD 0.00, 95% CI -0.19 to 0.19; 3 trials; N = 37). 'Once a day' gentamicin regimen was associated with fewer failures to attain peak level of at least 5 µg/ml (typical RR 0.22, 95% CI 0.11 to 0.47; typical RD -0.13, 95% CI -0.19 to -0.08; number needed to treat for an additional beneficial outcome (NNTB) = 8; 9 trials; N = 422); and fewer failures to achieve trough levels of 2 µg/ml or less (typical RR 0.38, 95% CI 0.27 to 0.55; typical RD -0.22, 95% CI -0.29 to -0.15; NNTB = 4; 11 trials; N = 503). 'Once a day' gentamicin achieved higher peak levels (MD 2.58, 95% CI 2.26 to 2.89; 10 trials; N = 440) and lower trough levels (MD -0.57, 95% CI -0.69 to -0.44; 10 trials; N = 440) than 'multiple doses a day' regimen. There was no significant difference in ototoxicity between two groups (typical RR 1.69, 95% CI 0.18 to 16.25; typical RD 0.01, 95% CI -0.04 to 0.05; 5 trials; N = 214). Nephrotoxicity was not noted with either of the treatment regimens. Overall, the quality of evidence was considered to be moderate on GRADE analysis, given the small sample size and unclear/high risk of bias in some of the domains in a few of the included studies. AUTHORS' CONCLUSIONS There is insufficient evidence from the currently available RCTs to conclude whether a 'once a day' or a 'multiple doses a day' regimen of gentamicin is superior in treating proven neonatal sepsis. However, data suggest that pharmacokinetic properties of a 'once a day' gentamicin regimen are superior to a 'multiple doses a day' regimen in that it achieves higher peak levels while avoiding toxic trough levels. There was no change in nephrotoxicity or auditory toxicity. Based on the assessment of pharmacokinetics, a 'once a day regimen' may be superior in treating sepsis in neonates of more than 32 weeks' gestation.
Collapse
Affiliation(s)
- Shripada C Rao
- King Edward Memorial Hospital for Women and Princess Margaret Hospital for ChildrenCentre for Neonatal Research and EducationPerth, Western AustraliaAustralia6008
| | - Ravisha Srinivasjois
- University of Western Australia, Joondalup Health CampusNeonatology and PaediatricsJoondalupWAAustralia
| | - Kwi Moon
- Princess Margaret Hospital for ChildrenPerthAustralia
| | | |
Collapse
|
40
|
Germovsek E, Barker CIS, Sharland M, Standing JF. Scaling clearance in paediatric pharmacokinetics: All models are wrong, which are useful? Br J Clin Pharmacol 2016; 83:777-790. [PMID: 27767204 PMCID: PMC5346879 DOI: 10.1111/bcp.13160] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/06/2016] [Accepted: 10/15/2016] [Indexed: 12/11/2022] Open
Abstract
Linked Articles This article is commented on in the editorial by Holford NHG and Anderson BJ. Why standards are useful for predicting doses. Br J Clin Pharmacol 2017; 83: 685–7. doi: 10.1111/bcp.13230 Aim When different models for weight and age are used in paediatric pharmacokinetic studies it is difficult to compare parameters between studies or perform model‐based meta‐analyses. This study aimed to compare published models with the proposed standard model (allometric weight0.75 and sigmoidal maturation function). Methods A systematic literature search was undertaken to identify published clearance (CL) reports for gentamicin and midazolam and all published models for scaling clearance in children. Each model was fitted to the CL values for gentamicin and midazolam, and the results compared with the standard model (allometric weight exponent of 0.75, along with a sigmoidal maturation function estimating the time in weeks of postmenstrual age to reach half the mature value and a shape parameter). For comparison, we also looked at allometric size models with no age effect, the influence of estimating the allometric exponent in the standard model and, for gentamicin, using a fixed allometric exponent of 0.632 as per a study on glomerular filtration rate maturation. Akaike information criteria (AIC) and visual predictive checks were used for evaluation. Results No model gave an improved AIC in all age groups, but one model for gentamicin and three models for midazolam gave slightly improved global AIC fits albeit using more parameters: AIC drop (number of parameters), –4.1 (5), –9.2 (4), –10.8 (5) and –10.1 (5), respectively. The 95% confidence interval of estimated CL for all top performing models overlapped. Conclusion No evidence to reject the standard model was found; given the benefits of standardised parameterisation, its use should therefore be recommended.
Collapse
Affiliation(s)
- Eva Germovsek
- Inflammation, Infection and Rheumatology Section, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK
| | - Charlotte I S Barker
- Inflammation, Infection and Rheumatology Section, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.,St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK.,St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Joseph F Standing
- Inflammation, Infection and Rheumatology Section, Great Ormond Street Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.,Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, Cranmer Terrace, London, SW17 0RE, UK
| |
Collapse
|
41
|
A Multiagent System for Dynamic Data Aggregation in Medical Research. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9027457. [PMID: 27975063 PMCID: PMC5128729 DOI: 10.1155/2016/9027457] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/23/2016] [Accepted: 10/18/2016] [Indexed: 11/28/2022]
Abstract
The collection of medical data for research purposes is a challenging and long-lasting process. In an effort to accelerate and facilitate this process we propose a new framework for dynamic aggregation of medical data from distributed sources. We use agent-based coordination between medical and research institutions. Our system employs principles of peer-to-peer network organization and coordination models to search over already constructed distributed databases and to identify the potential contributors when a new database has to be built. Our framework takes into account both the requirements of a research study and current data availability. This leads to better definition of database characteristics such as schema, content, and privacy parameters. We show that this approach enables a more efficient way to collect data for medical research.
Collapse
|
42
|
Decosterd L, Widmer N, André P, Aouri M, Buclin T. The emerging role of multiplex tandem mass spectrometry analysis for therapeutic drug monitoring and personalized medicine. Trends Analyt Chem 2016. [DOI: 10.1016/j.trac.2016.03.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
43
|
Antimicrobial Agent Dosing in Infants. Clin Ther 2016; 38:1948-60. [DOI: 10.1016/j.clinthera.2016.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/19/2022]
|
44
|
Development and Evaluation of a Gentamicin Pharmacokinetic Model That Facilitates Opportunistic Gentamicin Therapeutic Drug Monitoring in Neonates and Infants. Antimicrob Agents Chemother 2016; 60:4869-77. [PMID: 27270281 DOI: 10.1128/aac.00577-16] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/25/2016] [Indexed: 11/20/2022] Open
Abstract
Trough gentamicin therapeutic drug monitoring (TDM) is time-consuming, disruptive to neonatal clinical care, and a patient safety issue. Bayesian models could allow TDM to be performed opportunistically at the time of routine blood tests. This study aimed to develop and prospectively evaluate a new gentamicin model and a novel Bayesian computer tool (neoGent) for TDM use in neonatal intensive care. We also evaluated model performance for predicting peak concentrations and the area under the concentration-time curve from time 0 h to time t h (AUC0- t). A pharmacokinetic meta-analysis was performed on pooled data from three studies (1,325 concentrations from 205 patients). A 3-compartment model was used with the following covariates: allometric weight scaling, postmenstrual and postnatal age, and serum creatinine concentration. Final parameter estimates (standard errors) were as follows: clearance, 6.2 (0.3) liters/h/70 kg of body weight; central volume (V), 26.5 (0.6) liters/70 kg; intercompartmental disposition (Q), 2.2 (0.3) liters/h/70 kg; peripheral volume V2, 21.2 (1.5) liters/70 kg; intercompartmental disposition (Q2), 0.3 (0.05) liters/h/70 kg; peripheral volume V3, 148 (52.0) liters/70 kg. The model's ability to predict trough concentrations from an opportunistic sample was evaluated in a prospective observational cohort study that included data from 163 patients and 483 concentrations collected in five hospitals. Unbiased trough predictions were obtained; the median (95% confidence interval [CI]) prediction error was 0.0004 (-1.07, 0.84) mg/liter. Results also showed that peaks and AUC0- t values could be predicted (from one randomly selected sample) with little bias but relative imprecision, with median (95% CI) prediction errors being 0.16 (-4.76, 5.01) mg/liter and 10.8 (-24.9, 62.2) mg · h/liter, respectively. neoGent was implemented in R/NONMEM and in the freely available TDMx software.
Collapse
|
45
|
Gentamicin Exposure and Sensorineural Hearing Loss in Preterm Infants. PLoS One 2016; 11:e0158806. [PMID: 27390846 PMCID: PMC4938424 DOI: 10.1371/journal.pone.0158806] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 06/22/2016] [Indexed: 11/21/2022] Open
Abstract
Objective To evaluate the impact of gentamicin exposure on sensorineural hearing loss (SNHL) in very low birth weight (VLBW) infants. Methods Exposure to gentamicin was determined in infants born between 1993 and 2010 at a gestational age < 32 weeks and/or with a birthweight < 1500 g, who presented with SNHL during the first 5 years of life. For each case, we selected two controls matched for gender, gestational age, birthweight, and year of birth. Results We identified 25 infants affected by SNHL, leading to an incidence of SNHL of 1.58% in our population of VLBW infants. The proportion of infants treated with gentamicin was 76% in the study group and 70% in controls (p = 0.78). The total cumulated dose of gentamicin administered did not differ between the study group (median 10.2 mg/kg, Q1-Q3 1.6–13.2) and the control group (median 7.9 mg/kg, Q1-Q3 0–12.8, p = 0.47). The median duration of gentamicin treatment was 3 days both in the study group and the control group (p = 0.58). Maximum predicted trough serum levels of gentamicin, cumulative area under the curve and gentamicin clearance were not different between cases and controls. Conclusion The impact of gentamicin on SNHL can be minimized with treatments of short duration, monitoring of blood levels and dose adjustment.
Collapse
|
46
|
Bijleveld YA, de Haan TR, van der Lee HJH, Groenendaal F, Dijk PH, van Heijst A, de Jonge RCJ, Dijkman KP, van Straaten HLM, Rijken M, Zonnenberg IA, Cools F, Zecic A, Nuytemans DHGM, van Kaam AH, Mathot RAA. Altered gentamicin pharmacokinetics in term neonates undergoing controlled hypothermia. Br J Clin Pharmacol 2016; 81:1067-77. [PMID: 26763684 PMCID: PMC4876193 DOI: 10.1111/bcp.12883] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 01/05/2016] [Accepted: 01/10/2016] [Indexed: 11/29/2022] Open
Abstract
AIM(S) Little is known about the pharmacokinetic (PK) properties of gentamicin in newborns undergoing controlled hypothermia after suffering from hypoxic−ischaemic encephalopathy due to perinatal asphyxia. This study prospectively evaluates and describes the population PK of gentamicin in these patients METHODS Demographic, clinical and laboratory data of patients included in a multicentre prospective observational cohort study (the ‘PharmaCool Study’) were collected. A non-linear mixed-effects regression analysis (nonmem®) was performed to describe the population PK of gentamicin. The most optimal dosing regimen was evaluated based on simulations of the final model. RESULTS A total of 47 patients receiving gentamicin were included in the analysis. The PK were best described by an allometric two compartment model with gestational age (GA) as a covariate on clearance (CL). During hypothermia the CL of a typical patient (3 kg, GA 40 weeks, 2 days post-natal age (PNA)) was 0.06 l kg−1 h−1 (inter-individual variability (IIV) 26.6%) and volume of distribution of the central compartment (Vc) was 0.46 l kg−1 (IIV 40.8%). CL was constant during hypothermia and rewarming, but increased by 29% after reaching normothermia (>96 h PNA). CONCLUSIONS This study describes the PK of gentamicin in neonates undergoing controlled hypothermia. The 29% higher CL in the normothermic phase compared with the preceding phases suggests a delay in normalization of CL after rewarming has occurred. Based on simulations we recommend an empiric dose of 5 mg kg−1 every 36 h or every 24 h for patients with GA 36–40 weeks and GA 42 weeks, respectively.
Collapse
Affiliation(s)
| | - Timo R de Haan
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam
| | - Hanneke J H van der Lee
- Pediatric Clinical Research Office, Division Woman-Child, Academic Medical Center, University of Amsterdam, Amsterdam
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht
| | - Peter H Dijk
- Department of Neonatology, University Medical Center Groningen, Groningen
| | - Arno van Heijst
- Department of Neonatology, Radboud University Medical Center, Nijmegen
| | - Rogier C J de Jonge
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam
| | - Koen P Dijkman
- Department of Neonatology, Máxima Medical Center Veldhoven, Veldhoven
| | | | - Monique Rijken
- Department of Neonatology, Leiden University Medical Center, Leiden
| | - Inge A Zonnenberg
- Department of Neonatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Filip Cools
- Department of Neonatology, Vrije Universiteit Brussel, Brussels
| | - Alexandra Zecic
- Department of Neonatology, Academic Medical Center, Gent, Belgium
| | | | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam
| | - Ron A A Mathot
- Department of Pharmacy, Academic Medical Center, Amsterdam
| |
Collapse
|
47
|
Wilbaux M, Fuchs A, Samardzic J, Rodieux F, Csajka C, Allegaert K, van den Anker JN, Pfister M. Pharmacometric Approaches to Personalize Use of Primarily Renally Eliminated Antibiotics in Preterm and Term Neonates. J Clin Pharmacol 2016; 56:909-35. [PMID: 26766774 DOI: 10.1002/jcph.705] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 12/13/2022]
Abstract
Sepsis remains a major cause of mortality and morbidity in neonates, and, as a consequence, antibiotics are the most frequently prescribed drugs in this vulnerable patient population. Growth and dynamic maturation processes during the first weeks of life result in large inter- and intrasubject variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics. In this review we (1) summarize the available population PK data and models for primarily renally eliminated antibiotics, (2) discuss quantitative approaches to account for effects of growth and maturation processes on drug exposure and response, (3) evaluate current dose recommendations, and (4) identify opportunities to further optimize and personalize dosing strategies of these antibiotics in preterm and term neonates. Although population PK models have been developed for several of these drugs, exposure-response relationships of primarily renally eliminated antibiotics in these fragile infants are not well understood, monitoring strategies remain inconsistent, and consensus on optimal, personalized dosing of these drugs in these patients is absent. Tailored PK/PD studies and models are useful to better understand relationships between drug exposures and microbiological or clinical outcomes. Pharmacometric modeling and simulation approaches facilitate quantitative evaluation and optimization of treatment strategies. National and international collaborations and platforms are essential to standardize and harmonize not only studies and models but also monitoring and dosing strategies. Simple bedside decision tools assist clinical pharmacologists and neonatologists in their efforts to fine-tune and personalize the use of primarily renally eliminated antibiotics in term and preterm neonates.
Collapse
Affiliation(s)
- Mélanie Wilbaux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Aline Fuchs
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Janko Samardzic
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Frédérique Rodieux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Chantal Csajka
- Division of Clinical Pharmacology, Service of Biomedicine, Department of Laboratory, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Belgium.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johannes N van den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Marc Pfister
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Quantitative Solutions LP, Menlo Park, CA, USA
| |
Collapse
|
48
|
Samardzic J, Allegaert K, Wilbaux M, Pfister M, van den Anker JN. Quantitative clinical pharmacology practice for optimal use of antibiotics during the neonatal period. Expert Opin Drug Metab Toxicol 2016; 12:367-75. [PMID: 26817821 DOI: 10.1517/17425255.2016.1147559] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION For safe and effective neonatal antibiotic therapy, knowledge of the pharmacokinetic parameters of antibacterial agents in neonates is a prerequisite. Fast maturational changes during the neonatal period influence pharmacokinetic and pharmacodynamic parameters and their variability. Consequently, the need for applying quantitative clinical pharmacology and determining optimal drug dosing regimens in neonates has become increasingly recognized. AREAS COVERED Modern quantitative approaches, such as pharmacometrics, are increasingly utilized to characterize, understand and predict the pharmacokinetics of a drug and its effect, and to quantify the variability in the neonatal population. Individual factors, called covariates in modeling, are integrated in such approaches to explain inter-individual pharmacokinetic variability. Pharmacometrics has been shown to be a relevant tool to evaluate, optimize and individualize drug dosing regimens. EXPERT OPINION Challenges for optimal use of antibiotics in neonates can largely be overcome with quantitative clinical pharmacology practice. Clinicians should be aware that there is a next step to support the clinical decision-making based on clinical characteristics and therapeutic drug monitoring, through Bayesian-based modeling and simulation methods. Pharmacometric modeling and simulation approaches permit us to characterize population average, inter-subject and intra-subject variability of pharmacokinetic parameters such as clearance and volume of distribution, and to identify and quantify key factors that influence the pharmacokinetic behavior of antibiotics during the neonatal period.
Collapse
Affiliation(s)
- Janko Samardzic
- a Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty , University of Belgrade , Belgrade , Serbia.,b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Karel Allegaert
- c Department of Development and Regeneration , KU Leuven , Leuven , Belgium.,d Intensive Care and Department of Pediatric Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , the Netherlands
| | - Mélanie Wilbaux
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - Marc Pfister
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland
| | - John N van den Anker
- b Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,d Intensive Care and Department of Pediatric Surgery , Erasmus MC Sophia Children's Hospital , Rotterdam , the Netherlands.,e Division of Pediatric Clinical Pharmacology , Children's National Medical Center , Washington , DC , USA
| |
Collapse
|