1
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Singu BS, Verbeeck RK, Pieper CH, Ette EI. Confirming the Suitability of a Gentamicin Dosing Strategy in Neonates Using the Population Pharmacokinetic Approach with Truncated Sampling Duration. CHILDREN (BASEL, SWITZERLAND) 2024; 11:898. [PMID: 39201833 PMCID: PMC11352679 DOI: 10.3390/children11080898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/15/2024] [Accepted: 05/17/2024] [Indexed: 09/03/2024]
Abstract
(1) Background: Gentamicin is known to be nephrotoxic and ototoxic. Although gentamicin dosage guidelines have been established for preterm and term neonates, reports do show attainment of recommended peak concentrations but toxic gentamicin concentrations are common in this age group. (2) Methods: This was a prospective, observational study conducted in Namibia with 52 neonates. A dose of 5 mg/kg gentamicin was administered over 3-5 s every 24 h in combination with benzylpenicillin 100,000 IU/kg/12 h or ampicillin 50 mg/kg/8 h. Two blood samples were collected from each participant using a truncated pharmacokinetic sampling schedule. (3) Results: The one-compartment linear pharmacokinetic model best described the data. Birthweight, postnatal age, and white blood cell count were predictive of clearance (CL), while birthweight was predictive of volume (V). For the typical neonate (median weight 1.57 kg, median postnatal age 4 days (0.011 years), median log-transformed WBC of 2.39), predicted CL and V were 0.069 L/h and 0.417 L, respectively-similar to literature values. Simulated gentamicin concentrations varied with respect to postnatal age and bodyweight. (4) Conclusions: A 5 mg/kg/24 h dosage regimen yielded simulated gentamicin concentrations with respect to age and birthweight similar to those previously reported in the literature to be safe and efficacious, confirming its appropriateness.
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Affiliation(s)
- Bonifasius Siyuka Singu
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia, Windhoek Private Bag 13301, Namibia; (R.K.V.); (E.I.E.)
| | - Roger Karel Verbeeck
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia, Windhoek Private Bag 13301, Namibia; (R.K.V.); (E.I.E.)
| | | | - Ene I. Ette
- School of Pharmacy, Faculty of Health Sciences & Veterinary Medicine, University of Namibia, Windhoek Private Bag 13301, Namibia; (R.K.V.); (E.I.E.)
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2
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Abou-Auda HS, Alotaibi F, Alsanea S, Alwhaibi A, Almutairi MM, Alrabiah Z, Alsultan A, Al Jeraisy M. Population pharmacokinetics of gentamicin in acute lymphoblastic leukemia pediatric patients compared to non-oncology patients. Saudi Pharm J 2024; 32:102060. [PMID: 38596317 PMCID: PMC11002851 DOI: 10.1016/j.jsps.2024.102060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/31/2024] [Indexed: 04/11/2024] Open
Abstract
Understanding the pharmacokinetics of gentamicin is essential in special populations, such as pediatric patients with acute lymphoblastic leukemia (ALL), in light of previous studies indicating that ALL patients have a lower volume of distribution than non-ALL patients. Furthermore, validation of such results is needed to ensure their clinical application. Accordingly, this single-center, retrospective, cross-sectional study compares the pharmacokinetic parameters of volume of distribution and clearance (Cl) of gentamicin between ALL and non-ALL patients. Inclusion criteria were pediatric patients aged between 1 and 14 years with or without ALL and receiving intravenous gentamicin for treatment courses > 72 h. Patients' characteristics, such as age, sex, height, serum albumin, diagnosis, serum creatinine (Scr) concentration, dosing, and pharmacokinetic information, including peak and trough concentrations, were retrieved. The study scrutinized a total of 115 pediatric patients, comprising toddlers (15.7 %), children (76.5 %), and adolescents (7.8 %). All patients received gentamicin every 8 h, with an average dose of 2.50 (0.64) mg/kg. Patients were divided into two groups based on disease state, with 45.2 % (n = 52) in the non-ALL group and 54.8 % (n = 63) in the ALL group. Both groups had similar characteristics in terms of gender, weight, body surface area, and dose. The only significant covariates identified were weight and creatinine clearance (Clcr) for volume of distribution (Vd). A significant difference was found in Scr, Clcr, and blood urea nitrogen (BUN); however, no significant difference between ALL and non-ALL patients emerged in the volume of distribution or Cl. In conclusion, the study findings indicate that dosing requirements were similar between the two groups. Further prospective studies with larger sample sizes are warranted.
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Affiliation(s)
- Hisham S. Abou-Auda
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Fatimah Alotaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- King Abdullah Specialist Children's Hospital, Ministry of National Guard, Saudi Arabia
| | - Sary Alsanea
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohammed M. Almutairi
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ziyad Alrabiah
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Alsultan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Majed Al Jeraisy
- King Abdullah Specialist Children's Hospital, Ministry of National Guard, Saudi Arabia
- King Abdullah International Medical Research Center, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Saudi Arabia
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3
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Soeorg H, Padari H, Ilmoja ML, Herodes K, Kipper K, Lutsar I, Metsvaht T. Prediction of C-reactive protein dynamics during meropenem treatment in neonates and infants. Br J Clin Pharmacol 2024; 90:801-811. [PMID: 37903648 DOI: 10.1111/bcp.15950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 11/01/2023] Open
Abstract
AIMS C-reactive protein (CRP) is used to determine the effect of antibiotic treatment on sepsis in neonates/infants. We aimed to develop pharmacokinetic-pharmacodynamic (PKPD) model of meropenem and CRP in neonates/infants and evaluate its predictive performance of CRP dynamics. METHODS Data from neonates/infants treated with meropenem in 3 previous studies were analysed. To the previously developed meropenem PK models, the addition of turnover, transit or effect compartment, delay differential equation PD models of CRP as a function of meropenem concentration or its cumulative area under the curve (AUC) were evaluated. The percentage of neonates/infants (P0.1 , P0.2 ) in whom the ratio of the fifth day CRP to its peak value was predicted with an error of <0.1 (<0.2) was calculated. RESULTS A total of 60 meropenem treatment episodes (median [range] gestational age 27.6 [22.6-40.9] weeks, postnatal age 13 [2-89] days) with a total of 351 CRP concentrations (maximum value 65.5 [13-358.4] mg/L) were included. Turnover model of CRP as a function of meropenem cumulative AUC provided the best fit and included CRP at the start of treatment, use of prior antibiotics, study and causative agent Staphylococcus aureus or enterococci as covariates. Using meropenem population predictions and data available at 0, 24, 48, 72 h after the start of treatment, P0.1 (P0.2 ) was 36.4, 36.4, 60.6 and 66.7% (70.0, 66.7, 72.7 and 78.7%), respectively. CONCLUSION The developed PKPD model of meropenem and CRP as a function of meropenem cumulative AUC incorporating several patient characteristics predicts CRP dynamics with an error of <0.2 in most neonates/infants.
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Affiliation(s)
- Hiie Soeorg
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Helgi Padari
- Pediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
| | - Mari-Liis Ilmoja
- Pediatric Intensive Care Unit, Tallinn Children's Hospital, Tallinn, Estonia
| | - Koit Herodes
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - Karin Kipper
- Institute of Chemistry, University of Tartu, Tartu, Estonia
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Tuuli Metsvaht
- Department of Microbiology, University of Tartu, Tartu, Estonia
- Pediatric Intensive Care Unit, Tartu University Hospital, Tartu, Estonia
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4
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Allegaert K, Smits A, Annaert P. Interdisciplinary Collaboration on Real World Data to Close the Knowledge Gap: A Reflection on "De Sutter et al. Predicting Volume of Distribution in Neonates: Performance of Physiologically Based Pharmacokinetic Modelling". Pharmaceutics 2024; 16:128. [PMID: 38276498 PMCID: PMC10819087 DOI: 10.3390/pharmaceutics16010128] [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: 11/25/2023] [Revised: 12/28/2023] [Accepted: 01/16/2024] [Indexed: 01/27/2024] Open
Abstract
This commentary further reflects on the paper of De Sutter et al. on predicting volume of distribution in neonates, and the performance of physiologically based pharmacokinetic models We hereby stressed the add on value to collaborate on real world data to further close this knowledge gap. We illustrated this by weight distribution characteristics in breastfed (physiology) and in asphyxiated (pathophysiology), with additional reflection on their kidney and liver function.
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Affiliation(s)
- Karel Allegaert
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Hospital Pharmacy, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Neonatal Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Pieter Annaert
- Drug Delivery and Disposition, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium;
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5
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Daniels K, Arrieta A, Nieves DJ, Bhakta K, Tran MT, Osborne S, Morphew T. Ampicillin and Gentamicin Treatment for Early Onset Neonatal Sepsis: When One Size Does Not Fit All. Clin Pediatr (Phila) 2023; 62:1027-1031. [PMID: 36691803 DOI: 10.1177/00099228221150612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Based on in vitro susceptibilities and the concern for emergence of resistance and long-term safety, ampicillin plus gentamicin remains the recommended antibiotic regimen for early onset neonatal sepsis. Our objective was to identify potential limitations of this regimen based on clinical and pathogen characteristics while minimizing risks associated with prolonged antibiotic exposure. We identified 43 gram-negative pathogens in 42 patients. Escherichia coli (E coli) occurred in 50% and Streptococcus agalactiae in 23.8% of patient. Ampicillin resistance was common, particularly in E coli (85.7%). Mortality was 23.8%, all due to E coli. We found that E coli is the most frequent pathogen and has a high mortality particularly in neonates < 1500 g; mortality is high with the current dosing strategy when E coli is resistant to ampicillin even when sensitive to gentamicin; resistance to gentamicin remains low but seems to be increasing while resistance to third-generation cephalosporins remains very low.
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Affiliation(s)
| | - Antonio Arrieta
- Pediatric Infectious Diseases, CHOC Children's Hospital, Orange, CA, USA
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Delma J Nieves
- Pediatric Infectious Diseases, CHOC Children's Hospital, Orange, CA, USA
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Kushal Bhakta
- Department of Pediatrics, School of Medicine, University of California, Irvine, Irvine, CA, USA
- Neonatology, CHOC Children's Hospital, Orange, CA, USA
| | - M Tuan Tran
- Pharmacy Services, CHOC Children's Hospital, Orange, CA, USA
| | | | - Tricia Morphew
- CHOC Research Institute, CHOC Children's Hospital, Orange, CA, USA
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6
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De Sutter PJ, Rossignol P, Breëns L, Gasthuys E, Vermeulen A. Predicting Volume of Distribution in Neonates: Performance of Physiologically Based Pharmacokinetic Modelling. Pharmaceutics 2023; 15:2348. [PMID: 37765316 PMCID: PMC10536587 DOI: 10.3390/pharmaceutics15092348] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
The volume of distribution at steady state (Vss) in neonates is still often estimated through isometric scaling from adult values, disregarding developmental changes beyond body weight. This study aimed to compare the accuracy of two physiologically based pharmacokinetic (PBPK) Vss prediction methods in neonates (Poulin & Theil with Berezhkovskiy correction (P&T+) and Rodgers & Rowland (R&R)) with isometrical scaling. PBPK models were developed for 24 drugs using in-vitro and in-silico data. Simulations were done in Simcyp (V22) using predefined populations. Clinical data from 86 studies in neonates (including preterms) were used for comparison, and accuracy was assessed using (absolute) average fold errors ((A)AFEs). Isometric scaling resulted in underestimated Vss values in neonates (AFE: 0.61), and both PBPK methods reduced the magnitude of underprediction (AFE: 0.82-0.83). The P&T+ method demonstrated superior overall accuracy compared to isometric scaling (AAFE of 1.68 and 1.77, respectively), while the R&R method exhibited lower overall accuracy (AAFE: 2.03). Drug characteristics (LogP and ionization type) and inclusion of preterm neonates did not significantly impact the magnitude of error associated with isometric scaling or PBPK modeling. These results highlight both the limitations and the applicability of PBPK methods for the prediction of Vss in the absence of clinical data.
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7
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Hollander EM, van Tuinen EL, Schölvinck EH, Bergman KA, Bourgonje AR, Gracchi V, Kneyber MCJ, Touw DJ, Mian P. Evaluation of Dosing Guidelines for Gentamicin in Neonates and Children. Antibiotics (Basel) 2023; 12:antibiotics12050810. [PMID: 37237713 DOI: 10.3390/antibiotics12050810] [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: 03/24/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Although aminoglycosides are frequently prescribed to neonates and children, the ability to reach effective and safe target concentrations with the currently used dosing regimens remains unclear. This study aims to evaluate the target attainment of the currently used dosing regimens for gentamicin in neonates and children. We conducted a retrospective single-center cohort study in neonates and children receiving gentamicin between January 2019 and July 2022, in the Beatrix Children's Hospital. The first gentamicin concentration used for therapeutic drug monitoring was collected for each patient, in conjunction with information on dosing and clinical status. Target trough concentrations were ≤1 mg/L for neonates and ≤0.5 mg/L for children. Target peak concentrations were 8-12 mg/L for neonates and 15-20 mg/L for children. In total, 658 patients were included (335 neonates and 323 children). Trough concentrations were outside the target range in 46.2% and 9.9% of neonates and children, respectively. Peak concentrations were outside the target range in 46.0% and 68.7% of neonates and children, respectively. In children, higher creatinine concentrations were associated with higher gentamicin trough concentrations. This study corroborates earlier observational studies showing that, with a standard dose, drug concentration targets were met in only approximately 50% of the cases. Our findings show that additional parameters are needed to improve target attainment.
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Affiliation(s)
- Esther M Hollander
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Eline L van Tuinen
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Elisabeth H Schölvinck
- Department of Pediatric Infectious Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Klasien A Bergman
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Arno R Bourgonje
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Valentina Gracchi
- Division of Pediatric Nephrology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Peadiatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital Groningen, University Medical Center Groningen, University of Groningen Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daan J Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Department of Pharmaceutical Analysis, Groningen Research Institute for Pharmacy, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Paola Mian
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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8
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Sherwin CM, Tran NK, Sullivan K, Wead S, Birnbaum AK, Avachat C, Healy DP, Kagan RJ. Exploring the Past to Inform the Future to Optimize the Pharmacokinetics of Vancomycin in Children With Severe Burn Injuries. J Burn Care Res 2023; 44:353-362. [PMID: 36194537 DOI: 10.1093/jbcr/irac147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Indexed: 11/12/2022]
Abstract
Sepsis remains one of the leading causes of death among pediatric patients with burn injuries. Despite limited vancomycin pharmacokinetic (PK) information within this population, it is widely used to treat severe burn injuries. Those with severe burns are at risk of nephrotoxicity, with an incidence of acute kidney injury (AKI) over 50%. Delivering an effective vancomycin dose and avoiding unnecessary toxicity is essential for improved patient outcomes. This was a retrospective analysis of 115 children aged 0.2 months to 18 years with severe burns, >10% total body surface area. Vancomycin was given via intravenous infusion; blood samples were drawn between 6- and 12-hour postinfusion. A population pharmacokinetic model was developed using nonlinear mixed-effect modeling (Monolix, version 2016R1). A one-compartment model described a steady-state volume of distribution (V), dependent on weight. Vancomycin clearance (CL) was influenced by age and estimated creatinine clearance (CrCL). The study population's (median age = 4 years, median weight = 20 kg, median total body surface area (%TBSA) = 40%) median V and CL were calculated to be 1.25 L/kg (95% CI, 1.04-1.46) and 0.15 L/h/kg (95% CI, 0.126-0.165), respectively. The PK model was explicitly developed to characterize the impact of physiological changes in children under 18 years of age and the percentage of the burn surface area using limited data. The analysis determined that weight, age, and estimated CrCL were important covariates in predicting vancomycin PK with high variability in CL and V.
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Affiliation(s)
- Catherine M Sherwin
- Dept of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH, USA.,Dayton Children's Hospital, Dayton, OhH, USA.,James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, School of Medicine, Davis, CA, USA
| | - Kevin Sullivan
- University of Tennessee Medical Center and College of Pharmacy, Knoxville, TN, USA
| | | | - Angela K Birnbaum
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Charul Avachat
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Daniel P Healy
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
| | - Richard J Kagan
- The Shriners Hospitals for Children®, Dayton (Cincinnati), OH, USA.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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9
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Kayser N, Cunningham K, Alabsi S, Smith H. Targeting Lower Serum Trough Concentrations: A New Gentamicin Dosing Strategy for Suspected Neonatal Early-Onset Sepsis. J Pediatr Pharmacol Ther 2023; 28:71-77. [PMID: 36777986 PMCID: PMC9901316 DOI: 10.5863/1551-6776-28.1.71] [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: 11/10/2020] [Accepted: 06/09/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Neonatal gentamicin dosing algorithms are not designed to achieve serum trough concentrations ≤1 mcg/mL. The purpose of our study was to evaluate a new gentamicin algorithm based on serum creatinine (SCr) and gestational age (GA) designed to achieve serum gentamicin trough concentrations ≤1 mcg/mL. METHODS A retrospective cohort study was conducted in a level IIIB neonatal intensive care unit. The incidence of elevated serum gentamicin troughs for this study was compared with the center's previously published results to evaluate the proposed dosing algorithm. Patients were included if gentamicin was administered within the first 7 days of life and a serum gentamicin trough concentration and a baseline SCr concentration were obtained. Patients were further subdivided into groups based on GA for data analysis: ≤30 weeks (group 1), 30-34 weeks (group 2), and ≥35 weeks (group 3). The SCr was considered mildly elevated (0.81-0.99 mg/dL) or elevated (≥1 mg/dL). The respective outcomes between the post-algorithm and control groups were examined using intention-to-treat analysis and Bayesian modeling to calculate rate differences. RESULTS Of the 2377 patients evaluated, 366 met the inclusion criteria. Significantly lower percentages of elevated serum gentamicin troughs were noted in groups 2 and 3 subsequent to the implementation of the dosing algorithm with 16% and 15% lower rate differences, respectively. Regardless of GA, there were significantly fewer elevated serum troughs in the post-implementation groups than in the control with mildly elevated and elevated SCr p < 0.001. CONCLUSIONS Using a dosing algorithm based on SCr significantly reduced the number of elevated serum trough rates in neonates with a GA greater than 30 weeks.
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Affiliation(s)
- Nicholas Kayser
- Department of Pharmacy (NK, KC), UnityPoint Des Moines–Blank Children's Hospital, Des Moines, IA
| | - Kelli Cunningham
- Department of Pharmacy (NK, KC), UnityPoint Des Moines–Blank Children's Hospital, Des Moines, IA
| | - Samir Alabsi
- Neonatal Intensive Care Unit (SA), UnityPoint Des Moines–Blank Children's Hospital, Des Moines, IA
| | - Hayden Smith
- Education and Research Department (HS), UnityPoint Des Moines–Iowa Methodist Medical Center, Des Moines, IA
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10
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Pharmacokinetics of Antibiotics in Pediatric Intensive Care: Fostering Variability to Attain Precision Medicine. Antibiotics (Basel) 2021; 10:antibiotics10101182. [PMID: 34680763 PMCID: PMC8532953 DOI: 10.3390/antibiotics10101182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 12/16/2022] Open
Abstract
Children show important developmental and maturational changes, which may contribute greatly to pharmacokinetic (PK) variability observed in pediatric patients. These PK alterations are further enhanced by disease-related, non-maturational factors. Specific to the intensive care setting, such factors include critical illness, inflammatory status, augmented renal clearance (ARC), as well as therapeutic interventions (e.g., extracorporeal organ support systems or whole-body hypothermia [WBH]). This narrative review illustrates the relevance of both maturational and non-maturational changes in absorption, distribution, metabolism, and excretion (ADME) applied to antibiotics. It hereby provides a focused assessment of the available literature on the impact of critical illness—in general, and in specific subpopulations (ARC, extracorporeal organ support systems, WBH)—on PK and potential underexposure in children and neonates. Overall, literature discussing antibiotic PK alterations in pediatric intensive care is scarce. Most studies describe antibiotics commonly monitored in clinical practice such as vancomycin and aminoglycosides. Because of the large PK variability, therapeutic drug monitoring, further extended to other antibiotics, and integration of model-informed precision dosing in clinical practice are suggested to optimise antibiotic dose and exposure in each newborn, infant, or child during intensive care.
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11
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Sridharan K, Al Jufairi M, Qader AM, Elsegai OAM. Dose Optimization of Gentamicin in Critically Ill Neonates. Curr Drug Metab 2021; 21:270-280. [PMID: 32394828 DOI: 10.2174/1389200221666200512111131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/11/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Appropriate dosing of gentamicin in critically ill neonates is still debated. OBJECTIVE To assess the peak concentration (Cmax) and area-under-the-time-concentration curve (AUC0-24) of gentamicin and to simulate the recommended doses using the Monte Carlo method. METHODS This was a retrospective study on critically ill neonates carried over a one-year period. The demographic characteristics, dosage regimen and gentamicin concentrations were recorded for each neonate. Using Bayesian pharmacokinetic modeling, Cmax and AUC0-24 were predicted. Dose recommendations for the target Cmax (μg/ml) of 12 were obtained, and Monte Carlo simulation (100,000 iterations) was used for predicting the pharmacokinetic parameters and recommended doses for various birth weight categories. RESULTS Eighty-two critically ill neonates (with an average gestational age of 33.7 weeks; and birth weight of 2.1 kg) were recruited. Higher Cmax and AUC0-24 values were predicted in premature neonates, with greater cumulative AUCs in extremely preterm neonates. The average administered dose was 4 mg/kg/day and 75% of the participants had Cmax greater than 12 μg/ml following a single dose, and 85% were found to be at steady state. On the contrary, only 25% of the study population had the recommended AUC0-24 (above 125 μg-hr/ml). Simulation tests indicate that 90% of the critically ill neonates would achieve recommended Cmax with doses ranging between 5 and 6 mg/kg/day. CONCLUSION Currently used dose of 4 mg/kg/day is adequate to maintain Cmax in a large majority of the study population, with one-fourth population reporting the recommended AUC0-24. Increasing the dose to 5-6 mg/kg/day will more likely help to achieve both the recommended Cmax and AUC0-24 values.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Muna Al Jufairi
- Department of Pediatrics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Bahrain.,Neonatal Intensive Care Unit, Salmaniya Medical Hospital, Ministry of Health, Manama, Bahrain
| | - Ali Mohamed Qader
- College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Ola A M Elsegai
- Department of Pathology-Biochemistry, Salmaniya Medical Hospital, Ministry of Health, Manama, Bahrain
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12
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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.
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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
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13
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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.
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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
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Smits A, De Cock P, Vermeulen A, Allegaert K. Physiologically based pharmacokinetic (PBPK) modeling and simulation in neonatal drug development: how clinicians can contribute. Expert Opin Drug Metab Toxicol 2018; 15:25-34. [PMID: 30554542 DOI: 10.1080/17425255.2019.1558205] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: Legal initiatives to stimulate neonatal drug development should be accompanied by development of valid research tools. Physiologically based (PB)-pharmacokinetic (PK) modeling and simulation are established tools, accepted by regulatory authorities. Consequently, PBPK holds promise to be a strong research tool to support neonatal drug development. Area covered: The currently available PBPK models still have poor predictive performance in neonates. Using an illustrative approach on distinct PK processes of absorption, distribution, metabolism, excretion, and real-world data in neonates, we provide evidence on the need to further refine available PBPK system parameters through generation and integration of new knowledge. This necessitates cross talk between clinicians and modelers to integrate knowledge (PK datasets, system knowledge, maturational physiology) or test and refine PBPK models. Expert opinion: Besides refining these models for 'small molecules', PBPK model development should also be more widely applied for therapeutic proteins and to determine exposure through breastfeeding. Researchers should also be aware that PBPK modeling in combination with clinical observations can also be used to elucidate age-related changes that are almost impossible to study based on in vivo or in vitro data. This approach has been explored for hepatic biliary excretion, renal tubular activity, and central nervous system exposure.
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Affiliation(s)
- Anne Smits
- a Neonatal Intensive Care Unit , University Hospitals Leuven , Leuven , Belgium.,b Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Pieter De Cock
- c Department of Pharmacy , Ghent University Hospital , Ghent , Belgium.,d Heymans Institute of Pharmacology , Ghent University , Ghent , Belgium.,e Department of Pediatric Intensive Care , Ghent University , Ghent , Belgium
| | - An Vermeulen
- f Laboratory of Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences , Ghent University , Ghent , Belgium
| | - Karel Allegaert
- b Department of Development and Regeneration , KU Leuven , Leuven , Belgium.,g Department of Pediatrics, Division of Neonatology , Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , The Netherlands
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15
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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: 22] [Impact Index Per Article: 3.7] [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.
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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
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16
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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: 17] [Impact Index Per Article: 2.4] [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.
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17
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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: 87] [Impact Index Per Article: 10.9] [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.
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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
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18
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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]
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19
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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.
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20
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Fuchs A, Guidi M, Giannoni E, Werner D, Buclin T, Widmer N, Csajka C. Population pharmacokinetic study of gentamicin in a large cohort of premature and term neonates. Br J Clin Pharmacol 2015; 78:1090-101. [PMID: 24938850 DOI: 10.1111/bcp.12444] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 06/09/2014] [Indexed: 12/01/2022] Open
Abstract
AIM This study aims to investigate the clinical and demographic factors influencing gentamicin pharmacokinetics in a large cohort of unselected premature and term newborns and to evaluate optimal regimens in this population. METHODS All gentamicin concentration data, along with clinical and demographic characteristics, were retrieved from medical charts in a Neonatal Intensive Care Unit over 5 years within the frame of a routine therapeutic drug monitoring programme. Data were described using non-linear mixed-effects regression analysis ( nonmem®). RESULTS A total of 3039 gentamicin concentrations collected in 994 preterm and 455 term newborns were included in the analysis. A two compartment model best characterized gentamicin disposition. The average parameter estimates, for a median body weight of 2170 g, were clearance (CL) 0.089 l h(-1) (CV 28%), central volume of distribution (Vc ) 0.908 l (CV 18%), intercompartmental clearance (Q) 0.157 l h(-1) and peripheral volume of distribution (Vp ) 0.560 l. Body weight, gestational age and post-natal age positively influenced CL. Dopamine co-administration had a significant negative effect on CL, whereas the influence of indomethacin and furosemide was not significant. Both body weight and gestational age significantly influenced Vc . Model-based simulations confirmed that, compared with term neonates, preterm infants need higher doses, superior to 4 mg kg(-1) , at extended intervals to achieve adequate concentrations. CONCLUSIONS This observational study conducted in a large cohort of newborns confirms the importance of body weight and gestational age for dosage adjustment. The model will serve to set up dosing recommendations and elaborate a Bayesian tool for dosage individualization based on concentration monitoring.
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Affiliation(s)
- Aline Fuchs
- Division of Clinical Pharmacology, Service of Biomedicine, Department of Laboratory, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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21
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Prospective Evaluation of a Model-Based Dosing Regimen for Amikacin in Preterm and Term Neonates in Clinical Practice. Antimicrob Agents Chemother 2015; 59:6344-51. [PMID: 26248375 DOI: 10.1128/aac.01157-15] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/22/2015] [Indexed: 11/20/2022] Open
Abstract
Based on a previously derived population pharmacokinetic model, a novel neonatal amikacin dosing regimen was developed. The aim of the current study was to prospectively evaluate this dosing regimen. First, early (before and after second dose) therapeutic drug monitoring (TDM) observations were evaluated for achieving target trough (<3 mg/liter) and peak (>24 mg/liter) levels. Second, all observed TDM concentrations were compared with model-predicted concentrations, whereby the results of a normalized prediction distribution error (NPDE) were considered. Subsequently, Monte Carlo simulations were performed. Finally, remaining causes limiting amikacin predictability (i.e., prescription errors and disease characteristics of outliers) were explored. In 579 neonates (median birth body weight, 2,285 [range, 420 to 4,850] g; postnatal age 2 days [range, 1 to 30 days]; gestational age, 34 weeks [range, 24 to 41 weeks]), 90.5% of the observed early peak levels reached 24 mg/liter, and 60.2% of the trough levels were <3 mg/liter (93.4% ≤5 mg/liter). Observations were accurately predicted by the model without bias, which was confirmed by the NPDE. Monte Carlo simulations showed that peak concentrations of >24 mg/liter were reached at steady state in almost all patients. Trough values of <3 mg/liter at steady state were documented in 78% to 100% and 45% to 96% of simulated cases with and without ibuprofen coadministration, respectively; suboptimal trough levels were found in patients with postnatal age <14 days and current weight of >2,000 g. Prospective evaluation of a model-based neonatal amikacin dosing regimen resulted in optimized peak and trough concentrations in almost all patients. Slightly adapted dosing for patient subgroups with suboptimal trough levels was proposed. This model-based approach improves neonatal dosing individualization.
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Lutsar I, Telling K, Metsvaht T. Treatment option for sepsis in children in the era of antibiotic resistance. Expert Rev Anti Infect Ther 2014; 12:1237-52. [PMID: 25189378 DOI: 10.1586/14787210.2014.956093] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Sepsis caused by multidrug-resistant microorganisms is one of the most serious infectious diseases of childhood and poses significant challenges for pediatricians involved in management of critically ill children. This review discusses the use of pharmacokinetic/dynamic principles (i.e., prolonged infusion of β-lactams and vancomycin, once-daily administration of aminoglycosides and rationale of therapeutic drug monitoring) when prescribing antibiotics to critically ill patients. The potential of 'old' agents (i.e., colistin, fosfomycin) and newly approved antibiotics is critically reviewed. The pros and cons of combination antibacterial therapy are discussed and finally suggestions for the treatment of sepsis caused by multidrug-resistant organisms are provided.
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Affiliation(s)
- Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Ravila 19, 50411 Tartu, Estonia
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23
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Roberts JK, Stockmann C, Constance JE, Stiers J, Spigarelli MG, Ward RM, Sherwin CMT. Pharmacokinetics and Pharmacodynamics of Antibacterials, Antifungals, and Antivirals Used Most Frequently in Neonates and Infants. Clin Pharmacokinet 2014; 53:581-610. [DOI: 10.1007/s40262-014-0147-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Medlicott NJ, Reith DM, McCaffrey F, Krittaphol W, Broadbent RS. Delayed delivery of intravenous gentamicin in neonates: impact of infusion variables. J Pharm Pharmacol 2012; 65:370-8. [DOI: 10.1111/jphp.12000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 10/16/2012] [Indexed: 11/30/2022]
Abstract
Abstract
Objective
To investigate infusion variables that delay delivery of gentamicin through neonatal infusion lines.
Methods
Infusions were set up to simulate administration of gentamicin to neonates. The primary infusion was 10% dextrose (Baxter Colleague pump). A syringe driver was used to deliver a coloured marker via the T-connection over 35 min followed by a 1 ml normal saline flush over 35 min. Effects of dextrose concentration, primary infusion rate, dose volume and angle of the primary line were investigated. Gentamicin adsorption to in-line filters (Poisdyne Neo) and administration protocols from different neonatal intensive care units were also investigated.
Key findings
Low dose volumes (<0.4 ml) infused into slow-flowing glucose (dextrose) lines (3.8–4 ml/h) did not mix well at the T-connection. Coloured solutions formed an upper layer that moved in a retrograde direction towards the primary infusion bag. Gentamicin did not adsorb onto Posidyne Neo filters. Comparison of infusion protocols for gentamicin administration showed that slow infusion (30 min) into slow-flowing lines (4 ml/h) containing 10% glucose gave low recovery of drug during the infusion (<30% of intended dose).
Conclusions
Poor mixing at the T-connection appears to be the cause of delayed and/or incomplete gentamicin delivery for low dose volumes and slow infusion rates.
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Affiliation(s)
- Natalie J Medlicott
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - David M Reith
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Frances McCaffrey
- Neonatal Intensive Care Unit, Southern Regional Health Board, Dunedin, New Zealand
| | - Woravimol Krittaphol
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Roland S Broadbent
- Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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25
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Smits A, De Cock RFW, Cossey V, Knibbe CAJ, Allegaert K. Is indirect hyperbilirubinemia a useful biomarker of reduced propofol clearance in neonates? Biomark Med 2012; 6:283-9. [PMID: 22731901 DOI: 10.2217/bmm.12.25] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
AIM Large interindividual variability in neonatal propofol clearance is documented which, in part, can be explained by postmenstrual age (PMA) and postnatal age (PNA). We aimed to document whether indirect bilirubin, instead of or in addition to PNA, could improve predictability of propofol clearance and serve as a useful biomarker of reduced propofol clearance in neonates. METHODS Indirect serum bilirubin was introduced as a dichotomous or continuous variable (both age-normalized) in a previously developed three-compartment pharmacokinetic model, based on 235 concentration-time points obtained in 25 neonates after single bolus administration of propofol. For pharmacokinetic analysis, nonlinear mixed effect modeling 6.2 was used. RESULTS The covariates PMA and PNA explained 67% of the interindividual variability compared with 45% in the model with PMA and bilirubin. CONCLUSION Age, reflected by PMA and PNA, is a more relevant clinical predictor of neonatal propofol clearance compared with PMA and raised indirect hyperbilirubinemia.
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Affiliation(s)
- Anne Smits
- Neonatal intensive care unit, University Hospitals Leuven, Belgium.
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26
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Campbell SC, Spigarelli MG, Courter J, Sherwin CMT. Metabolic and toxicological considerations for sepsis drug treatments. Expert Opin Drug Metab Toxicol 2012; 9:79-89. [DOI: 10.1517/17425255.2012.727396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Short versus long infusion of meropenem in very-low-birth-weight neonates. Antimicrob Agents Chemother 2012; 56:4760-4. [PMID: 22733063 DOI: 10.1128/aac.00655-12] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Prolonged infusion of meropenem has been suggested in studies with population pharmacokinetic modeling but has not been tested in neonates. We compared the steady-state pharmacokinetics (PK) of meropenem given as a short (30-min) or prolonged (4-h) infusion to very-low-birth-weight (gestational age, <32 weeks; birth weight, <1,200 g) neonates to define the appropriate dosing regimen for a phase 3 efficacy study. Short (n = 9) or prolonged (n = 10) infusions of meropenem were given at a dose of 20 mg/kg every 12 h. Immediately before and 0.5, 1.5, 4, 8, and 12 h after the 4th to 7th doses of meropenem, blood samples were collected. Meropenem concentrations were measured by ultrahigh-performance liquid chromatography. PK analysis was performed with WinNonlin software, and modeling was performed with NONMEM software. A short infusion resulted in a higher mean drug concentration in serum (C(max)) than a prolonged infusion (89 versus 54 mg/liter). In all but two patients in the prolonged-infusion group, the free serum drug concentration was above the MIC (2 mg/liter) 100% of the time. Meropenem clearance (CL) was not influenced by postnatal or postmenstrual age. In population PK analysis, a one-compartment model provided the best fit and the steady-state distribution volume (V(ss)) was scaled with body weight and CL with a published renal maturation function. The covariates serum creatinine and postnatal and gestational ages did not improve the model fit. The final parameter estimates were a V(ss) of 0.301 liter/kg and a CL of 0.061 liter/h/kg. Meropenem infusions of 30 min are acceptable as they balance a reasonably high C(max) with convenience of dosing. In very-low-birth-weight neonates, no dosing adjustment is needed over the first month of life.
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Fullas F, Padomek MT, Thieman CJ, Van Gorp AE. Comparative evaluation of six extended-interval gentamicin dosing regimens in premature and full-term neonates. Am J Health Syst Pharm 2011; 68:52-6. [PMID: 21164066 DOI: 10.2146/ajhp100114] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Six extended-interval gentamicin dosing regimens were comparatively evaluated in premature and full-term neonates. METHODS Data regarding six physician-ordered dosing regimens of gentamicin for neonates in a hospital neonatal intensive care unit were collected and analyzed. Neonates of gestational age (GA) 29 weeks or younger received 4.5 mg/kg every 48 hours. Neonates of GA 30-34 weeks received one of three dosing regimens: 3.5, 4, or 4.5 mg/kg every 36 hours. Neonates of GA 35 weeks or older received either 3.5 or 4 mg/kg every 24 hours. Blood samples were collected 30 minutes before and 30 minutes after the third dose was infused for binary trough and peak level determinations, respectively. RESULTS Peak gentamicin concentrations in the target range were attained most often in neonates of GA 29 weeks or younger who received gentamicin 4.5 mg/kg every 48 hours, in neonates of GA 30-34 weeks treated with gentamicin 3.5 mg/kg every 36 hours, and in neonates of GA 35 weeks or older treated with gentamicin 3.5 mg/kg every 24 hours. CONCLUSION For neonates of GA 30-34 weeks, gentamicin 3.5 mg/kg every 36 hours resulted in the highest percentage of peaks in the target range compared with 4 and 4.5 mg/kg every 36 hours. For neonates of GA 35 weeks or older, gentamicin 3.5 mg/kg every 24 hours provided the highest percentage of peaks in the target range compared with 4 mg/kg every 24 hours. The differences between the percentages of trough values in the target range of 0.5-2 μg/mL were not significant among dosing subgroups within each age group.
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Affiliation(s)
- Fekadu Fullas
- Pharmacy Department, St. Luke’s Regional Medical Center, 2720 Stone Park Boulevard, Sioux City, IA 51104, USA.
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Sherwin CMT, Kostan E, Broadbent RS, Medlicott NJ, Reith DM. Evaluation of the effect of intravenous volume expanders upon the volume of distribution of gentamicin in septic neonates. Biopharm Drug Dispos 2009; 30:276-80. [DOI: 10.1002/bdd.666] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Sherwin CMT, Svahn S, Van Der Linden A, Broadbent RS, Medlicott NJ, Reith DM. Individualised dosing of amikacin in neonates: a pharmacokinetic/pharmacodynamic analysis. Eur J Clin Pharmacol 2009; 65:705-13. [DOI: 10.1007/s00228-009-0637-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 02/11/2009] [Indexed: 10/21/2022]
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Begg EJ, Vella-Brincat JWA, Robertshawe B, McMurtrie MJ, Kirkpatrick CMJ, Darlow B. Eight years' experience of an extended-interval dosing protocol for gentamicin in neonates. J Antimicrob Chemother 2009; 63:1043-9. [DOI: 10.1093/jac/dkp073] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Allegaert K, Rayyan M, Vanhaesebrouck S, Naulaers G. Developmental pharmacokinetics in neonates. Expert Rev Clin Pharmacol 2008; 1:415-428. [DOI: 10.1586/17512433.1.3.415] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Seaton C, Ignas J, Muchohi S, Kokwaro G, Maitland K, Thomson AH. Population pharmacokinetics of a single daily intramuscular dose of gentamicin in children with severe malnutrition. J Antimicrob Chemother 2007; 59:681-9. [PMID: 17347177 DOI: 10.1093/jac/dkl561] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The World Health Organization recommends that all children admitted with severe malnutrition should routinely receive parenteral ampicillin and gentamicin; despite this, mortality remains high. Since this population group is at risk of altered volume of distribution, we aimed to study the population pharmacokinetics of once daily gentamicin (7.5 mg/kg) in children with severe malnutrition and to evaluate clinical factors affecting pharmacokinetic parameters. METHODS Thirty-four children aged 0.5-10 years were studied. One hundred and thirty-two gentamicin concentrations (median of four per patient), drawn 0.4-24.6 h after administration of the intramuscular dose, were analysed. The data were fitted by a two-compartment model using the population package NONMEM. RESULTS Gentamicin was rapidly absorbed and all concentrations measured within the first 2 h after administration were > 8 mg/L (indicating that satisfactory peak concentrations were achieved). Ninety-eight percent of samples measured more than 20 h after the dose were < 1 mg/L. The best model included weight, and it was found that high base deficit, high creatinine concentration and low temperature (all markers of hypovolaemic shock) reduced clearance (CL/F). Weight influenced volume of the central (V1/F) and peripheral (V2/F) compartments, and high base deficit reduced V2/F and intercompartmental CL (Q/F). Interindividual variability in CL was 26%, in V1/F 33% and in V2/F and Q/F was 52%. Individual estimates of CL/F ranged from 0.02 to 0.16 (median 0.10) L/h/kg and those of Vss/F from 0.26 to 1.31 (median 0.67) L/kg. Initial half-lives had a median of 1.4 h and elimination half-lives and a median of 14.9 h. Excessive concentrations were observed in one patient who had signs of renal impairment and shock. CONCLUSIONS Although a daily dose of 7.5 mg/kg achieves satisfactory gentamicin concentrations in the majority of patients, patients with renal impairment and shock may be at risk of accumulation with 24 hourly dosing. Further studies of gentamicin pharmacokinetics in this group are now needed to inform future international guideline recommendations.
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Affiliation(s)
- Claire Seaton
- KEMRI-Wellcome Research Programme, Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute, PO Box 230, Kilifi, Kenya
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Tanigawara Y, Sato R, Morita K, Kaku M, Aikawa N, Shimizu K. Population pharmacokinetics of Arbekacin in patients infected with methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 2006; 50:3754-62. [PMID: 17065621 PMCID: PMC1635234 DOI: 10.1128/aac.00420-05] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Arbekacin, a derivative of dibekacin, is an aminoglycoside developed and widely used in Japan for the treatment of patients infected with methicillin-resistant Staphylococcus aureus (MRSA). The population pharmacokinetics of arbekacin was investigated in the Japanese, using 353 patients infected with MRSA and 50 healthy or renally impaired volunteers. The age of the study population ranged from 8 to 95 years, and weight ranged from 10.8 to 107 kg. In total, 1,581 serum arbekacin concentrations were measured (primarily from routine patient care) and used to perform the present pharmacokinetic analysis. Drug concentration-time data were well described by a two-compartment open model. Factors influencing arbekacin pharmacokinetics were investigated using a nonlinear mixed-effect model analysis. The best-developed model showed that drug clearance (CL) was related to creatinine clearance (CL(CR)), age, and body weight (WT), as expressed by CL (liter/h) = 0.0319CL(CR) + (26.5/age) (CL(CR) < 80 ml/min) and CL (liter/h) = 0.0130 CL(CR) + 0.0342WT + (26.5/age) (CL(CR) >/= 80 ml/min). The volume of distribution for the central and peripheral compartments was different in healthy subjects and infected patients, and this difference was more pronounced among disease types. The elderly subjects (aged 80 years or over) exhibited, on average, a 19% greater volume for the central compartment. The volumes for the peripheral compartment were 50.6 liters in patients with pneumonia and 24.3 liters in patients with sepsis. The population pharmacokinetic parameters of arbekacin obtained here are useful for optimal use of this aminoglycoside in the treatment of MRSA-infected patients.
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Affiliation(s)
- Yusuke Tanigawara
- Department of Hospital Pharmacy, School of Medicine, Keio University, Tokyo 160-8582, Japan.
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Anderson BJ, Allegaert K, Van den Anker JN, Cossey V, Holford NHG. Vancomycin pharmacokinetics in preterm neonates and the prediction of adult clearance. Br J Clin Pharmacol 2006; 63:75-84. [PMID: 16869817 PMCID: PMC2000709 DOI: 10.1111/j.1365-2125.2006.02725.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT *Effects of size, renal function, age (postnatal age, gestational age and postmenstrual age) as predictors of vancomycin clearance in premature neonates are established, but the relative contribution of each component remains poorly quantified, largely because these variables are closely correlated. *We have quantified the covariates contributing to vancomycin clearance population parameter variability in order to establish the major covariates required for dosing predictions. Size, standardized using allometric models, was the primary covariate used in our analysis. WHAT THIS STUDY ADDS *Size explained 49.8%, postmenstrual age 18.2% and renal function 14.1% of clearance variability. *Descriptors of the relationship between age and clearance in premature neonates vary. *The use of a variable slope sigmoidal model to describe the relationship between clearance and postmenstrual age predicted an adult clearance of 3.79 l h(-1) 70 kg(-1) (95% confidence interval 2.76, 4.98) from premature neonatal data. AIM To identify and quantify factors describing the variability of vancomycin clearance in premature neonates. METHODS Population pharmacokinetics were estimated (NONMEM) in 214 neonates [postmenstrual age (PMA) 30.4 weeks, range 24-34 weeks; postnatal age 11.9 days, range 1-27 days; weight 1.30 kg, range 0.42-2.6 kg] using therapeutic drug monitoring data. Covariate analysis included weight, PMA, serum creatinine, use of inotropes or ibuprofen, positive blood culture and respiratory support. A one-compartment linear disposition model with zero order input and first-order elimination was used to describe the data (604 observations). RESULTS The population estimate for volume of distribution (V) was 39 l 70 kg(-1) (coefficient of variation 19.4%). Clearance (CL) increased from 0.897 l h(-1) 70 kg(-1) at 24 weeks PMA to 2.02 l h(-1) 70 kg(-1) by 34 weeks PMA. The between-subject variability for CL was 18.6% and the between-occasion variability was 12.2%. The use of ibuprofen reduced clearance, but this effect was attributable to reduced renal function. Overall, 82% of the variability of CL was predictable. Size explained 49.8%, PMA 18.2% and renal function 14.1%. The use of a variable slope sigmoidal model to describe the relationship between clearance and PMA predicted an adult clearance of 3.79 l h(-1) 70 kg(-1) (95% confidence interval 2.76, 4.98). CONCLUSIONS Size, renal function and PMA are the major contributors to clearance variability in premature neonates. The small (18%) unexplained variability in clearance suggests target concentration intervention is unnecessary if size, age and renal function are used to predict the dose. Extrapolation to an adult clearance from neonatal data is possible using allometric size models and a function describing clearance maturation.
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Affiliation(s)
- Brian J Anderson
- Neonatal Intensive Care Unit, University Hospital Gasthuisberg, Leuven, Belgium.
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Allegaert K, Anderson BJ, Cossey V, Holford NHG. Limited predictability of amikacin clearance in extreme premature neonates at birth. Br J Clin Pharmacol 2006; 61:39-48. [PMID: 16390350 PMCID: PMC1884978 DOI: 10.1111/j.1365-2125.2005.02530.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIM Identify and quantify factors describing variability of amikacin clearance in preterm neonates at birth. METHODS Population pharmacokinetics of amikacin were estimated in a cohort of 205 extreme preterm neonates [post conception age (PCA) 27.8, SD 1.8, range 24-30 weeks; weight 1.07, SD 0.34, range 0.45-1.98 kg, postnatal age < 72 h]. Covariate analysis included weight, PCA, Apgar score, prophylactic administration of a nonsteroidal anti-inflammatory drug (NSAID) to the neonate, maternal indomethacin and betamethasone administration, and chorioamnionitis. RESULTS A one-compartment linear disposition model with zero order input (0.3 h i.v. infusion) and first-order elimination was used. The population parameter estimate for volume of distribution (V) was 40.2 l per 70 kg. Clearance (CL) increased from 0.486 l h(-1) per 70 kg at 24 weeks PCA to 0.940 l h(-1) per 70 kg by 30 weeks PCA. The population parameter variability (PPV) for CL and V was 0.336 and 0.451. The use of a NSAID (either aspirin or ibuprofen) in the first day of life reduced amikacin clearance by 22%. Overall 65% of the variability of CL was predictable. Weight explained 48%, PCA 15% and NSAIDs 2%. CONCLUSIONS Size and post-conception age are the major contributors to clearance variability in extreme premature neonates (<31 weeks PCA). The large (35% of total) unexplained variability in clearance reinforces the need for target concentration intervention to reduce variability in exposure to a safe and effective range.
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Affiliation(s)
- Karel Allegaert
- Neonatal Intensive Care Unit, University Hospital Gasthuisberg, Leuven, Belgium.
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