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Ngougni Pokem P, Vanneste D, Schouwenburg S, Abdulla A, Gijsen M, Dhont E, Van der Linden D, Spriet I, De Cock P, Koch B, Van Bambeke F, Wijnant GJ. Dose optimization of β-lactam antibiotics in children: from population pharmacokinetics to individualized therapy. Expert Opin Drug Metab Toxicol 2024:1-18. [PMID: 39078238 DOI: 10.1080/17425255.2024.2385403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/21/2024] [Accepted: 07/24/2024] [Indexed: 07/31/2024]
Abstract
INTRODUCTION β-Lactams are the most widely used antibiotics in children. Their optimal dosing is essential to maximize their efficacy, while minimizing the risk for toxicity and the further emergence of antimicrobial resistance. However, most β-lactams were developed and licensed long before regulatory changes mandated pharmacokinetic studies in children. As a result, pediatric dosing practices are poorly harmonized and off-label use remains common today. AREAS COVERED β-Lactam pharmacokinetics and dose optimization strategies in pediatrics, including fixed dose regimens, therapeutic drug monitoring, and model-informed precision dosing are reviewed. EXPERT OPINION/COMMENTARY Standard pediatric doses can result in subtherapeutic exposure and non-target attainment for specific patient subpopulations (neonates, critically ill children, e.g.). Such patients could benefit greatly from more individualized approaches to dose optimization, beyond a relatively simple dose adaptation based on weight, age, or renal function. In this context, Therapeutic Drug Monitoring (TDM) and Model-Informed Precision Dosing (MIPD) emerge as particularly promising avenues. Obstacles to their implementation include the lack of strong evidence of clinical benefit due to the paucity of randomized clinical trials, of standardized assays for monitoring concentrations, or of adequate markers for renal function. The development of precision medicine tools is urgently needed to individualize therapy in vulnerable pediatric subpopulations.
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Affiliation(s)
- Perrin Ngougni Pokem
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Department of Microbiology, Cliniques Universitaires Saint-Luc - Université catholique de Louvain, Brussels, Belgium
| | - Dorian Vanneste
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Stef Schouwenburg
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Evelyn Dhont
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
| | - Dimitri Van der Linden
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
- Pediatric Infectious Diseases, Service of Specialized Pediatrics, Department of Pediatrics, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Pharmacy Department, UZ Leuven, Leuven, Belgium
| | - Pieter De Cock
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Pediatric Intensive Care, Ghent University Hospital, Ghent, Belgium
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Birgit Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, Netherlands
- Rotterdam Clinical Pharmacometrics Group, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Françoise Van Bambeke
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Gert-Jan Wijnant
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
- Laboratory of Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Wu YE, Zheng YY, Li QY, Yao BF, Cao J, Liu HX, Hao GX, van den Anker J, Zheng Y, Zhao W. Model-informed drug development in pediatric, pregnancy and geriatric drug development: States of the art and future. Adv Drug Deliv Rev 2024; 211:115364. [PMID: 38936664 DOI: 10.1016/j.addr.2024.115364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 06/09/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
The challenges of drug development in pediatric, pregnant and geriatric populations are a worldwide concern shared by regulatory authorities, pharmaceutical companies, and healthcare professionals. Model-informed drug development (MIDD) can integrate and quantify real-world data of physiology, pharmacology, and disease processes by using modeling and simulation techniques to facilitate decision-making in drug development. In this article, we reviewed current MIDD policy updates, reflected on the integrity of physiological data used for MIDD and the effects of physiological changes on the drug PK, as well as summarized current MIDD strategies and applications, so as to present the state of the art of MIDD in pediatric, pregnant and geriatric populations. Some considerations are put forth for the future improvements of MIDD including refining regulatory considerations, improving the integrity of physiological data, applying the emerging technologies, and exploring the application of MIDD in new therapies like gene therapies for special populations.
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Affiliation(s)
- Yue-E Wu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuan-Yuan Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiu-Yue Li
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing Cao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA; Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA; Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.
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3
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Fornari C, Arrieta A, Bradley JS, Tout M, Magalhaes P, Auriol FK, Borella E, Piana C, Della Pasqua O, Vallespir BP, Mazzei P, Bokesch PM, Hoover R, Capriati A, Habboubi N. Dose rationale for the use of meropenem/vaborbactam combination in paediatric patients with Gram-negative bacterial infections. Br J Clin Pharmacol 2024. [PMID: 38925918 DOI: 10.1111/bcp.16145] [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: 06/19/2023] [Revised: 05/24/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024] Open
Abstract
AIMS Meropenem/vaborbactam combination is approved in adults by FDA and EMA for complicated urinary tract infections and by EMA also for other Gram-negative infections. We aimed to characterise the pharmacokinetics of both moieties in an ongoing study in children and use a model-based approach to inform adequate dosing regimens in paediatric patients. METHODS Over 4196 blood samples of meropenem and vaborbactam (n = 414 subjects) in adults, together with 114 blood samples (n = 39) in paediatric patients aged 3 months to 18 years were available for this analysis. Data were analysed using a population with prior information from a pharmacokinetic model in adults to inform parameter estimation in children. Simulations were performed to assess the suitability of different dosing regimens to achieve adequate probability of target attainment (PTA). RESULTS Meropenem/vaborbactam PK was described with two-compartment models with first-order elimination. Body weight and CLcr were significant covariates on the disposition of both drugs. A maturation function was evaluated to explore changes in clearance in neonates. PTA ≥90% was derived for children aged ≥3 months after 3.5-h IV infusion of 40 mg/kg Q8h of both meropenem and vaborbactam and 2 g/2 g for those ≥50 kg. Extrapolation of disposition parameters suggest that adequate PTA is achieved after a 3.5-h IV infusion of 20 mg/kg for neonates and infants (3 months). CONCLUSIONS An integrated analysis of adult and paediatric data allowed accurate description of sparsely sampled meropenem/vaborbactam PK in paediatric patients and provided recommendations for the dosing in neonates and infants (3 months).
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Affiliation(s)
- Chiara Fornari
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Antonio Arrieta
- Children's Hospital of Orange County, Orange, California, USA
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, San Diego, California, USA
- Rady Children's Hospital, San Diego, California, USA
| | - Mira Tout
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Paulo Magalhaes
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Faten Koraichi Auriol
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Elisa Borella
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Chiara Piana
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics, University College London, London, UK
| | - Bartomeu Piza Vallespir
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Paolo Mazzei
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | | | | | - Angela Capriati
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
| | - Nassir Habboubi
- Clinical Pharmacology, Pharmacometrics and Clinical DMPK Department, Stemline Therapeutics/Menarini Group, Pomezia, Italy
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Shah RV, Kipper K, Baker EH, Barker CIS, Oldfield I, Philips BJ, Johnston A, Lipman J, Rhodes A, Basarab M, Sharland M, Almahdi S, Wake RM, Standing JF, Lonsdale DO. Population Pharmacokinetic Study of Benzylpenicillin in Critically Unwell Adults. Antibiotics (Basel) 2023; 12:antibiotics12040643. [PMID: 37107004 PMCID: PMC10135101 DOI: 10.3390/antibiotics12040643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 04/29/2023] Open
Abstract
Pharmacokinetics are highly variable in critical illness, and suboptimal antibiotic exposure is associated with treatment failure. Benzylpenicillin is a commonly used beta-lactam antibiotic, and pharmacokinetic data of its use in critically ill adults are lacking. We performed a pharmacokinetic study of critically unwell patients receiving benzylpenicillin, using data from the ABDose study. Population pharmacokinetic modelling was undertaken using NONMEM version 7.5, and simulations using the final model were undertaken to optimize the pharmacokinetic profile. We included 77 samples from 12 participants. A two-compartment structural model provided the best fit, with allometric weight scaling for all parameters and a creatinine covariate effect on clearance. Simulations (n = 10,000) demonstrated that 25% of simulated patients receiving 2.4 g 4-hourly failed to achieve a conservative target of 50% of the dosing interval with free drug above the clinical breakpoint MIC (2 mg/L). Simulations demonstrated that target attainment was improved with continuous or extended dosing. To our knowledge, this study represents the first full population PK analysis of benzylpenicillin in critically ill adults.
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Affiliation(s)
- Reya V Shah
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
- Department of Clinical Pharmacology & Therapeutics, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Karin Kipper
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
- Institute of Chemistry, University of Tartu, 50411 Tartu, Estonia
- Analytical Services International Ltd., London SW17 0RE, UK
| | - Emma H Baker
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
- Department of Clinical Pharmacology & Therapeutics, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Charlotte I S Barker
- Department of Medical and Molecular Genetics, King's College London, London WC2R 2LS, UK
| | - Isobel Oldfield
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
| | | | - Atholl Johnston
- Analytical Services International Ltd., London SW17 0RE, UK
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London WC1E 7HU, UK
| | - Jeffrey Lipman
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Brisbane, QLD 4029, Australia
- The University of Queensland Centre for Clinical Research, Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, University of Montpellier, 30029 Nimes, France
| | - Andrew Rhodes
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Marina Basarab
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Mike Sharland
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
| | - Sarraa Almahdi
- London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - Rachel M Wake
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
- Clinical Academic Group in Infection and Immunity, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Joseph F Standing
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
- UCL Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Dagan O Lonsdale
- Institute for Infection and Immunity, St George's, University of London, London SW17 0RE, UK
- Department of Clinical Pharmacology & Therapeutics, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
- Department of Critical Care, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
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5
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Smit C, Sen S, von Dach E, Karmime A, Lescuyer P, Tonoli D, Bielicki J, Huttner A, Pfister M. Steering Away from Current Amoxicillin Dose Reductions in Hospitalized Patients with Impaired Kidney Function to Avoid Subtherapeutic Drug Exposure. Antibiotics (Basel) 2022; 11:antibiotics11091190. [PMID: 36139969 PMCID: PMC9494977 DOI: 10.3390/antibiotics11091190] [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: 06/29/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Current dose reductions recommended for amoxicillin in patients with impaired kidney function could lead to suboptimal treatments. In a prospective, observational study in hospitalized adults with varying kidney function treated with an IV or oral dose of amoxicillin, amoxicillin concentrations were measured in 1−2 samples on the second day of treatment. Pharmacometric modelling and simulations were performed to evaluate the probability of target attainment (PTA) for 40% of the time above MIC following standard (1000 mg q6h), reduced or increased IV dosing strategies. A total of 210 amoxicillin samples was collected from 155 patients with kidney function based on a CKD-EPI of between 12 and 165 mL/min/1.73 m2. Amoxicillin clearance could be well predicted with body weight and CKD-EPI. Recommended dose adjustments resulted in a clinically relevant reduction in the PTA for the nonspecies-related PK/PD breakpoint MIC of 8 mg/L (92%, 62% and 38% with a CKD-EPI of 10, 20 and 30 mL/min/1.73 m2, respectively, versus 100% for the standard dose). For MICs ≤ 2 mg/L, PTA > 90% was reached in these patients following both reduced and standard dose regimens. Our study showed that for amoxicillin, recommended dose reductions with impaired kidney function could lead to subtherapeutic amoxicillin concentrations in hospitalized patients, especially when targeting less susceptible pathogens.
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Affiliation(s)
- Cornelis Smit
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Department of Clinical Pharmacy, Antonius Hospital, 8601 ZK Sneek, The Netherlands
| | - Swapnoleena Sen
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland
- Swiss Tropical and Public Health Institute, 4056 Basel, Switzerland
| | - Elodie von Dach
- Center for Clinical Research, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
| | - Abderrahim Karmime
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Pierre Lescuyer
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - David Tonoli
- Division of Laboratory Medicine, Diagnostic Department, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Julia Bielicki
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George’s, University of London, London SW17 0RE, UK
| | - Angela Huttner
- Center for Clinical Research, Geneva University Hospitals and Faculty of Medicine, 1205 Geneva, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics Research Center, University of Basel Children’s Hospital (UKBB), 4056 Basel, Switzerland
- Certara, Princeton, NJ 08540, USA
- Correspondence: ; Tel.: +41-61-704-1212
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Hu TM. A General Biphasic Bodyweight Model for Scaling Basal Metabolic Rate, Glomerular Filtration Rate, and Drug Clearance from Birth to Adulthood. AAPS J 2022; 24:67. [PMID: 35538161 DOI: 10.1208/s12248-022-00716-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/26/2022] [Indexed: 02/06/2023] Open
Abstract
The objective of this study is to propose a unified, continuous, and bodyweight-only equation to quantify the changes of human basal metabolic rate (BMR), glomerular filtration rate (GFR), and drug clearance (CL) from infancy to adulthood. The BMR datasets were retrieved from a comprehensive historical database of male and female subjects (0.02 to 64 years). The CL datasets for 17 drugs and the GFR dataset were generated from published maturation and growth models with reported parameter values. A statistical approach was used to simulate the model-generated CL and GFR data for a hypothetical population with 26 age groups (from 0 to 20 years). A biphasic equation with two power-law functions of bodyweight was proposed and evaluated as a general model using nonlinear regression and dimensionless analysis. All datasets universally reveal biphasic curves with two distinct linear segments on log-log plots. The biphasic equation consists of two reciprocal allometric terms that asymptotically determine the overall curvature. The fitting results show a superlinear scaling phase (asymptotic exponent >1; ca. 1.5-3.5) and a sublinear scaling phase (asymptotic exponent <1; ca. 0.5-0.7), which are separated at the phase transition bodyweight ranging from 5 to 20 kg with a mean value of 10 kg (corresponding to 1 year of age). The dimensionless analysis generalizes and offers quantitative realization of the maturation and growth process. In conclusion, the proposed mixed-allometry equation is a generic model that quantitatively describes the phase transition in the human maturation process of diverse human functions.
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Affiliation(s)
- Teh-Min Hu
- Department of Pharmacy, School of Pharmaceutical Sciences, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan.
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7
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Gastine S, Obiero C, Kane Z, Williams P, Readman J, Murunga S, Thitiri J, Ellis S, Correia E, Nyaoke B, Kipper K, van den Anker J, Sharland M, Berkley JA, Standing JF. Simultaneous pharmacokinetic/pharmacodynamic (PKPD) assessment of ampicillin and gentamicin in the treatment of neonatal sepsis. J Antimicrob Chemother 2022; 77:448-456. [PMID: 35107141 PMCID: PMC8809196 DOI: 10.1093/jac/dkab413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives This study aimed to simultaneously investigate the pharmacokinetics of ampicillin and gentamicin, currently the WHO standard of care for treating neonatal sepsis. Methods Pharmacokinetic data were collected in 59 neonates receiving ampicillin and gentamicin for suspected or proven sepsis in the NeoFosfo trial (NCT03453177). A panel of 23 clinical Escherichia coli isolates from neonates with sepsis, resistant to either ampicillin, gentamicin or both, were tested for susceptibility using chequerboards. Pharmacokinetic/pharmacodynamic (PKPD) modelling and simulations were used to compare single-agent (EUCAST MIC) and combination (chequerboard MIC) target attainment with standard dosing regimens. Results A model was established that simultaneously estimated parameters of a one-compartment ampicillin model and a two-compartment gentamicin model. A common clearance for both drugs was used (6.89 L/h/70 kg) relating to glomerular filtration (CLGFR), with an additional clearance term added for ampicillin (5.3 L/h/70 kg). Covariate modelling included a priori allometric weight and post-menstrual age scaling of clearance. Further covariate relationships on renal clearance were postnatal age and serum creatinine. Simulation-based PKPD assessments suggest good Gram-positive (MIC ≤ 0.25 mg/L) cover. However, less than one-quarter of neonates were predicted to receive efficacious coverage against Enterobacterales (MIC ≤ 2 mg/L). The benefit of the ampicillin/gentamicin combination was limited, with only 2/23 E. coli clinical strains showing FIC index < 0.5 (synergy) and most in the range 0.5–1 (suggesting additivity). Simulations showed that feasible dosing strategies would be insufficient to cover resistant strains. Conclusions PKPD simulations showed ampicillin and gentamicin combination therapy was insufficient to cover Enterobacterales, suggesting the need for alternative empirical treatment options for neonatal sepsis.
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Affiliation(s)
- Silke Gastine
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Zoe Kane
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Quotient Sciences, Mere Way, Ruddington, Nottingham, UK
| | - Phoebe Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - John Readman
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | | | - Sally Ellis
- Global Antibiotic Research & Development Partnership (GARDP), Genève, Switzerland
| | - Erika Correia
- Global Antibiotic Research & Development Partnership (GARDP), Genève, Switzerland
| | - Borna Nyaoke
- Drugs for Neglected Diseases Initiative (DNDi), Nairobi, Kenya
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - John van den Anker
- Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, London, UK
| | - James A Berkley
- Quotient Sciences, Mere Way, Ruddington, Nottingham, UK.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Joseph F Standing
- Infection, Immunity and Inflammation, Great Ormond Street Institute of Child Health, University College London, London, UK.,Pharmacy Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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8
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Gastine S, Hsia Y, Clements M, Barker CI, Bielicki J, Hartmann C, Sharland M, Standing JF. Variation in Target Attainment of Beta-Lactam Antibiotic Dosing Between International Pediatric Formularies. Clin Pharmacol Ther 2021; 109:958-970. [PMID: 33521971 PMCID: PMC8358626 DOI: 10.1002/cpt.2180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/15/2021] [Indexed: 12/26/2022]
Abstract
As antimicrobial susceptibility of common bacterial pathogens decreases, ensuring optimal dosing may preserve the use of older antibiotics in order to limit the spread of resistance to newer agents. Beta-lactams represent the most widely prescribed antibiotic class, yet most were licensed prior to legislation changes mandating their study in children. As a result, significant heterogeneity persists in the pediatric doses used globally, along with quality of evidence used to inform dosing. This review summarizes dosing recommendations from the major pediatric reference sources and tries to answer the questions: Does beta-lactam dose heterogeneity matter? Does it impact pharmacodynamic target attainment? For three important severe clinical infections-pneumonia, sepsis, and meningitis-pharmacokinetic models were identified for common for beta-lactam antibiotics. Real-world demographics were derived from three multicenter point prevalence surveys. Simulation results were compared with minimum inhibitory concentration distributions to inform appropriateness of recommended doses in targeted and empiric treatment. While cephalosporin dosing regimens are largely adequate for target attainment, they also pose the most risk of neurotoxicity. Our review highlights aminopenicillin, piperacillin, and meropenem doses as potentially requiring review/optimization in order to preserve the use of these agents in future.
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Affiliation(s)
- Silke Gastine
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Yingfen Hsia
- School of PharmacyQueen’s University BelfastBelfastUK
| | | | - Charlotte I.S. Barker
- Department of Medical & Molecular GeneticsKing’s College LondonLondonUK
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Julia Bielicki
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
- Paediatric Pharmacology GroupUniversity of Basel Children’s HospitalBaselSwitzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research GroupInstitute for Infection and ImmunitySt George’s University of LondonLondonUK
| | - Joseph F. Standing
- Infection, Immunity and Inflammation Research and Teaching DepartmentUCL Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Department of PharmacyGreat Ormond Street Hospital for ChildrenLondonUK
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9
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Lonsdale DO, Kipper K, Baker EH, Barker CIS, Oldfield I, Philips BJ, Johnston A, Rhodes A, Sharland M, Standing JF. β-Lactam antimicrobial pharmacokinetics and target attainment in critically ill patients aged 1 day to 90 years: the ABDose study. J Antimicrob Chemother 2020; 75:3625-3634. [DOI: 10.1093/jac/dkaa363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/09/2020] [Indexed: 01/16/2023] Open
Abstract
Abstract
Background
The pharmacokinetics of β-lactam antibiotics in critical illness remain poorly characterized, particularly in neonates, children and the elderly. We undertook a pharmacokinetic study of commonly used β-lactam antibiotics in critically ill patients of all ages. The aims were to produce a whole-life β-lactam pharmacokinetic model and describe the extent to which standard doses achieve pharmacokinetic/pharmacodynamic targets associated with clinical cure.
Patients and methods
A total of 212 critically ill participants with an age range from 1 day (gestational age 24 weeks) to 90 years were recruited from a UK hospital, providing 1339 pharmacokinetic samples. Population pharmacokinetic analysis was undertaken using non-linear mixed-effects modelling (NONMEM) for each drug. Pooled data were used to estimate maturation and decline of β-lactam pharmacokinetics throughout life.
Results
Pharmacokinetic models for eight drugs were described, including what is thought to be the first benzylpenicillin model in critically ill adults. We estimate that 50% of adult β-lactam clearance is achieved by 43 weeks post-menstrual age (chronological plus gestational age). Fifty percent of decline from peak adult clearance occurs by 71 years. Paediatric participants were significantly less likely than adults to achieve pharmacokinetic/pharmacodynamic targets with standard antibiotic doses (P < 0.01).
Conclusions
We believe this to be the first prospective whole-life antibiotic pharmacokinetic study in the critically ill. The study provides further evidence that standard antibiotic doses fail to achieve pharmacokinetic/pharmacodynamic targets associated with clinical success in adults, children and neonates. Maturation and decline parameters estimated from this study could be adopted as a standard for future prospective studies.
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Affiliation(s)
- Dagan O Lonsdale
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Karin Kipper
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- Institute of Chemistry, University of Tartu, Tartu, Estonia
- Analytical Services International Ltd, London, UK
| | - Emma H Baker
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Charlotte I S Barker
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Isobel Oldfield
- Institute for Infection and Immunity, St George’s, University of London, London, UK
| | | | - Atholl Johnston
- Analytical Services International Ltd, London, UK
- Clinical Pharmacology, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Andrew Rhodes
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Mike Sharland
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Institute for Infection and Immunity, St George’s, University of London, London, UK
- UCL Great Ormond Street Institute of Child Health, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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10
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Parker SL, Abdul-Aziz MH, Roberts JA. The role of antibiotic pharmacokinetic studies performed post-licensing. Int J Antimicrob Agents 2020; 56:106165. [PMID: 32941948 DOI: 10.1016/j.ijantimicag.2020.106165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/29/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022]
Abstract
Post-licensing pharmacometric studies can provide a better understanding of the pharmacokinetic (PK) alterations in special patient populations and may lead to better clinical outcomes. Some patient populations exhibit markedly different pathophysiology to general ward patients or healthy individuals. This may be developmental (paediatric patients), a manifestation of an underlying disease pathology (patients with obesity or haematological malignancies) or due to medical interventions (critically ill patients receiving extracorporeal therapies). This paper outlines the factors that affect the PK of special patient populations and describes some novel methods of antimicrobial administration that may increase antimicrobial concentrations at the site of infection and improve treatment of severe infection.
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Affiliation(s)
- Suzanne L Parker
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia.
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia; Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
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11
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Lonsdale DO, Lipman J, Livermore A, McWhinney B, Ungerer JPJ, Roberts JA. Amoxicillin-Clavulanate Dosing in the Intensive Care Unit: The Additive Effect of Renal Replacement Therapy in a Patient with Normal Kidney Function. Chemotherapy 2020; 64:173-176. [PMID: 31940615 DOI: 10.1159/000505057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/27/2019] [Indexed: 11/19/2022]
Abstract
Dosing of amoxicillin-clavulanic acid in critical illness is difficult as β-lactam pharmacokinetics are altered by physiological changes and therapies initiated in the intensive care unit such as renal replacement therapy (RRT). Successful treatment relies on sustaining a free antibiotic concentration above the minimum inhibitory concentration of the target pathogen (fT>MIC). We present a case of a patient treated with amoxicillin-clavulanic acid (1.2 g for 8 h) for an aspiration pneumonia. Dosing in this case was complicated by the necessity for RRT to treat a drug overdose with carbamazepine, despite normal native renal function. Antibiotic concentrations taken at steady state revealed a clearance of 14.6 L/h and a low fT>MIC (<40%). Analysis of the urine drug concentration suggested that 48% of clearance was via the native kidneys. This case illustrates that careful consideration of antibiotic dose and frequency is required in critically ill patients receiving RRT and highlights the need for further research in this patient group. In future similar cases, we would consider a dose of 2.2 g 6- or 8-hourly with early therapeutic drug monitoring.
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Affiliation(s)
- Dagan Osborne Lonsdale
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia,
| | - Jeffrey Lipman
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Amelia Livermore
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Brett McWhinney
- Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
| | - Jacobus P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Departments of Pharmacy and Intensive Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
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12
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Population pharmacokinetics of meropenem in critically ill children with different renal functions. Eur J Clin Pharmacol 2019; 76:61-71. [DOI: 10.1007/s00228-019-02761-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
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13
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Pharmacokinetic–pharmacodynamic population modelling in paediatric anaesthesia and its clinical translation. Curr Opin Anaesthesiol 2019; 32:353-362. [DOI: 10.1097/aco.0000000000000725] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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14
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Vancomycin Pharmacokinetics Throughout Life: Results from a Pooled Population Analysis and Evaluation of Current Dosing Recommendations. Clin Pharmacokinet 2019; 58:767-780. [DOI: 10.1007/s40262-018-0727-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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15
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Lonsdale DO, Baker EH, Kipper K, Barker C, Philips B, Rhodes A, Sharland M, Standing JF. Scaling beta-lactam antimicrobial pharmacokinetics from early life to old age. Br J Clin Pharmacol 2018; 85:316-346. [PMID: 30176176 DOI: 10.1111/bcp.13756] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/02/2018] [Accepted: 08/22/2018] [Indexed: 12/13/2022] Open
Abstract
AIMS Beta-lactam dose optimization in critical care is a current priority. We aimed to review the pharmacokinetics (PK) of three commonly used beta-lactams (amoxicillin ± clavulanate, piperacillin-tazobactam and meropenem) to compare PK parameters reported in critically and noncritically ill neonates, children and adults, and to investigate whether allometric and maturation scaling principles could be applied to describe changes in PK parameters through life. METHODS A systematic review of PK studies of the three drugs was undertaken using MEDLINE and EMBASE. PK parameters and summary statistics were extracted and scaled using allometric principles to 70 kg individual for comparison. Pooled data were used to model clearance maturation and decline using a sigmoidal (Hill) function. RESULTS A total of 130 papers were identified. Age ranged from 29 weeks to 82 years and weight from 0.9-200 kg. PK parameters from critically ill populations were reported with wider confidence intervals than those in healthy volunteers, indicating greater PK variability in critical illness. The standard allometric size and sigmoidal maturation model adequately described increasing clearance in neonates, and a sigmoidal model was also used to describe decline in older age. Adult weight-adjusted clearance was achieved at approximately 2 years postmenstrual age. Changes in volume of distribution were well described by the standard allometric model, although amoxicillin data suggested a relatively higher volume of distribution in neonates. CONCLUSIONS Critical illness is associated with greater PK variability than in healthy volunteers. The maturation models presented will be useful for optimizing beta-lactam dosing, although a prospective, age-inclusive study is warranted for external validation.
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Affiliation(s)
- Dagan O Lonsdale
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Emma H Baker
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Karin Kipper
- Institute for Infection and Immunity, St George's, University of London, London, UK.,Institute of Chemistry, University of Tartu, Tartu, Estonia.,Analytical Services International Ltd
| | - Charlotte Barker
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Barbara Philips
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mike Sharland
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Joseph F Standing
- Institute for Infection and Immunity, St George's, University of London, London, UK.,St George's University Hospitals NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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