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Wade KC, Greenberg RG, Benjamin DK, Chen LLH, Vo B, Ang BL, Boutzoukas A, Zimmerman K, Clark RH, Cohen-Wolkowiez M, Le J. Postdiscontinuation Antibiotic Exposure in Hospitalized Infants at Risk for Late-onset Sepsis in the Neonatal Intensive Care Unit. Pediatr Infect Dis J 2024; 43:991-996. [PMID: 38900075 PMCID: PMC11408093 DOI: 10.1097/inf.0000000000004426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND In the neonatal intensive care unit, infants are at risk for late-onset sepsis. When blood cultures are negative, antibiotic stewardship efforts encourage stopping antibiotics, yet the duration of therapeutic exposure after the last dose is unknown. METHODS This retrospective cohort study of simulated antibiotic exposures used published population pharmacokinetic models within drug-specific neonatal intensive care unit cohorts of preterm and term infants, postnatal age 7-60 days and exposed to cefepime, piperacillin-tazobactam or tobramycin. Monte Carlo simulations (NONMEM 7.3) were used to predict steady-state exposures after a 72-hour antibiotic course per Neofax dosing. Exposure was assessed relative to drug-specific minimum inhibitory concentration (MIC) targets between 1 and 16 mcg/mL for Pseudomonas and Enterobacteriaceae species. Postdiscontinuation antibiotic exposure (PDAE) was defined as the time from the last dose to when antibiotic concentration decreased below a specific MIC. RESULTS Piperacillin-tazobactam, cefepime and tobramycin cohorts included infants with median gestation age 29, 32 and 32 weeks and postnatal age 17, 19 and 15 days, respectively. The mean PDAE was 19-68 hours, depending on the specific antibiotic/MIC combination. PDAE was longer for infants <28 days old and preterm (vs. term) infants. Cefepime exhibited the longest mean PDAE of 68 hours for Enterobacteriaceae MIC 1. Piperacillin mean PDAE was 25 hours for Enterobacteriaceae MIC 8. Tobramycin had a short mean PDAE of 19 hours. CONCLUSIONS Piperacillin and cefepime exposures remained therapeutic long after the expected 8- to 12-hour dosing interval. PDAE is an important consideration for antibiotic stewardship among hospitalized infants, particularly premature infants and those within 1 month postbirth.
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Affiliation(s)
- Kelly C Wade
- From the Department of Pediatrics, University of Pennsylvania School of Medicine
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University Medical Center
- Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel K Benjamin
- Department of Pediatrics, Duke University Medical Center
- Duke Clinical Research Institute, Durham, North Carolina
| | - Lydia Li-Hui Chen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, California
| | - Brandon Vo
- University of California Riverside, Riverside, California
| | - Berwyn Liselle Ang
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, California
| | - Angelique Boutzoukas
- Department of Pediatrics, Duke University Medical Center
- Duke Clinical Research Institute, Durham, North Carolina
| | - Kanecia Zimmerman
- Department of Pediatrics, Duke University Medical Center
- Duke Clinical Research Institute, Durham, North Carolina
| | - Reese H Clark
- MEDNAX Center for Research, Education, Quality, and Safety, Sunrise, Florida
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University Medical Center
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, California
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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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Regazzi M, Berardi A, Picone S, Tzialla C. Pharmacokinetic and Pharmacodynamic Considerations of Antibiotic Use in Neonates. Antibiotics (Basel) 2023; 12:1747. [PMID: 38136781 PMCID: PMC10740758 DOI: 10.3390/antibiotics12121747] [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: 11/13/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
The selection of an appropriate dose of a given antibiotic for a neonate not only requires knowledge of the drug's basic pharmacokinetic (PK) and pharmacodynamic (PD) properties but also the profound effects that organ development might have on the volume of distribution and clearance, both of which may affect the PK/PD of a drug. Interest has grown in alternative antibiotic dosing strategies that are better aligned with the antibiotic's PK and PD properties. These strategies should be used in conjunction with minimum inhibitory concentration measurements and therapeutic drug monitoring to measure their potential success. They can also guide the clinician in tailoring the delivery of antibiotics to suit an individual patient's needs. Model-informed precision dosing, such as Bayesian forecasting dosing software (which incorporates PK/PD population models), may be utilized to optimize antibiotic exposure in neonatal populations. Consequently, optimizing the antibiotic dose and exposure in each newborn requires expertise in different fields. It drives the collaboration of physicians together with lab technicians and quantitative clinical pharmacologists.
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Affiliation(s)
- Mario Regazzi
- S.I.F.E.B, Italian Society of Pharmacokinetics and Biopharmaceutics, 27100 Pavia, Italy
| | - Alberto Berardi
- Neonatal Intensive Care Unit, University Hospital of Modena, 41124 Modena, Italy;
| | - Simonetta Picone
- Neonatology and Neonatal Intensive Care Unit, Policlinico Casilino, 00169 Rome, Italy;
| | - Chryssoula Tzialla
- Neonatal and Pediatric Unit, Ospedale Civile Voghera, ASST Pavia, 27100 Pavia, Italy;
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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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Pais GM, Chang J, Barreto EF, Stitt G, Downes KJ, Alshaer MH, Lesnicki E, Panchal V, Bruzzone M, Bumanglag AV, Burke SN, Scheetz MH. Clinical Pharmacokinetics and Pharmacodynamics of Cefepime. Clin Pharmacokinet 2022; 61:929-953. [PMID: 35764774 PMCID: PMC9345683 DOI: 10.1007/s40262-022-01137-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
Cefepime is a broad-spectrum fourth-generation cephalosporin with activity against Gram-positive and Gram-negative pathogens. It is generally administered as an infusion over 30-60 min or as a prolonged infusion with infusion times from 3 h to continuous administration. Cefepime is widely distributed in biological fluids and tissues with an average volume of distribution of ~ 0.2 L/kg in healthy adults with normal renal function. Protein binding is relatively low (20%), and elimination is mainly renal. About 85% of the dose is excreted unchanged in the urine, with an elimination half-life of 2-2.3 h. The pharmacokinetics of cefepime is altered under certain pathophysiological conditions, resulting in high inter-individual variability in cefepime volume of distribution and clearance, which poses challenges for population dosing approaches. Consequently, therapeutic drug monitoring of cefepime may be beneficial in certain patients including those who are critically ill, have life-threatening infections, or are infected with more resistant pathogens. Cefepime is generally safe and efficacious, with a goal exposure target of 70% time of the free drug concentration over the minimum inhibitory concentration for clinical efficacy. In recent years, reports of neurotoxicity have increased, specifically in patients with impaired renal function. This review summarizes the pharmacokinetics, pharmacodynamics, and toxicodynamics of cefepime contemporarily in the setting of increasing cefepime exposures. We explore the potential benefits of extended or continuous infusions and therapeutic drug monitoring in special populations.
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Affiliation(s)
- Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | | | - Gideon Stitt
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin J Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Emily Lesnicki
- College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Vaidehi Panchal
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - Maria Bruzzone
- Division of Neurology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Argyle V Bumanglag
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sara N Burke
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA.
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA.
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de Cacqueray N, Hirt D, Zheng Y, Bille E, Leger PL, Rambaud J, Toubiana J, Chosidow A, Vimont S, Callot D, Chouchana L, Béranger A, Tréluyer JM, Benaboud S, Oualha M. Cefepime population pharmacokinetics and dosing regimen optimization in critically ill children with different renal function. Clin Microbiol Infect 2022; 28:1389.e1-1389.e7. [PMID: 35605841 DOI: 10.1016/j.cmi.2022.05.007] [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: 03/24/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Cefepime is commonly used in pediatric intensive care units (PICUs), where unpredictable variations in the patients' pharmacokinetic (PK) variables may require drug dose adjustments. The objectives of the present study were to build a population PK model for cefepime in critically ill children and to optimize individual initial dosing regimens. METHODS Children (aged from 1 month to 18 years; bodyweight >3 kg) receiving cefepime were included. Cefepime total plasma concentrations were measured using high performance liquid chromatography. Data were modelled using non-linear, mixed-effect modeling software, and Monte Carlo simulations were performed with a PK target of 100% fT > MIC. RESULTS Fifty-nine patients (median (range) age: 13.5 months (1.1 month-17.6 years)) and 129 cefepime concentration measurements were included. The cefepime concentration data were best fitted by a one-compartment model. The selected covariates were body weight with allometric scaling and estimated glomerular filtration rate on clearance. Mean population values for clearance and volume were 1.21 L.h-1 and 4.8 L, respectively. According to the simulations, a regimen of 100 mg.kg-1.day-1 q12 h over 30 min or 100 mg.kg-1.day-1 as a continuous infusion was more likely to achieve the PK target in patients with renal failure and in patients with normal or augmented renal clearance, respectively. CONCLUSIONS Appropriate cefepime dosing regimens should take renal function into account. Continuous infusions are required in critically ill children with normal or augmented renal clearance, while intermittent infusions are adequate for children with acute renal failure. Close therapeutic drug monitoring is mandatory, given cefepime's narrow therapeutic window.
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Affiliation(s)
- Noémie de Cacqueray
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris, AP-HP, France.
| | - Déborah Hirt
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris, AP-HP, France; Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris, France
| | - Yi Zheng
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris, AP-HP, France
| | - Emmanuelle Bille
- Microbiological Laboratory, Necker Enfants Malades Hospital, Université de Paris, France
| | - Pierre Louis Leger
- Department of Pediatric Intensive Care Unit, Armand Trousseau Hospital, Université de Paris, AP-HP, France
| | - Jérôme Rambaud
- Department of Pediatric Intensive Care Unit, Armand Trousseau Hospital, Université de Paris, AP-HP, France
| | - Julie Toubiana
- Department of General Pediatrics and Pediatric Infectious Diseases, Necker Enfants Malades Hospital
| | - Anais Chosidow
- Department of General Pediatrics, Armand Trousseau Hospital, Université de Paris, AP-HP, France
| | - Sophie Vimont
- Department of Bacteriology, Hôpital Saint Antoine, Université de Paris, AP-HP, France; Sorbonne University, UPMC, UMR S 1155, Paris, France; INSERM, UMR S 1155, Paris, France
| | - Delphine Callot
- Regional Center of Pharmacovigilance, Department of Pharmacology, Cochin Hospital, Université de Paris, AP-HP, France
| | - Laurent Chouchana
- Regional Center of Pharmacovigilance, Department of Pharmacology, Cochin Hospital, Université de Paris, AP-HP, France
| | - Agathe Béranger
- Department of Pediatric Cardiac Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris, AP-HP, France; Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris, France
| | - Jean Marc Tréluyer
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris, AP-HP, France; Department of Clinical Pharmacology, Cochin Hospital, Université de Paris, AP-HP, France; Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris, France
| | - Sihem Benaboud
- Department of Clinical Pharmacology, Cochin Hospital, Université de Paris, AP-HP, France
| | - Mehdi Oualha
- Department of Pediatric Intensive Care Unit, Necker Enfants Malades Hospital, Université de Paris, AP-HP, France; Pharmacology and Drug Evaluation in Children and Pregnant Women EA7323, Université de Paris, France
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Thibault C, Moorthy GS, Vedar C, Naim MY, DiLiberto MA, Zuppa AF. Pharmacokinetics of Cefepime in Children on Extracorporeal Membrane Oxygenation: External Model Validation, Model Improvement and Dose Optimization. Pediatr Infect Dis J 2022; 41:217-223. [PMID: 34817416 DOI: 10.1097/inf.0000000000003371] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Cefepime is a first-line therapy for Gram-negative infections in children on extracorporeal membrane oxygenation. Cefepime pharmacokinetics (PK) in children on extracorporeal membrane oxygenation still needs to be better established. METHODS This was a prospective single-center PK study. A maximum of 12 PK samples per patient were collected in children <18 years old on extracorporeal membrane oxygenation who received clinically indicated cefepime. External validation of a previously published population PK model was performed by applying the model in a new data set. The predictive performance of the model was determined by calculating prediction errors. Because of poor predictive performance, a revised model was developed using NONMEM and a combined data set that included data from both studies. Dose-exposure simulations were performed using the final model. Optimal dosing was judged based on the ability to maintain free cefepime concentrations above the minimal inhibitory concentration (MIC) for 68% and 100% of the dosing interval. RESULTS Seventeen children contributed 105 PK samples. The mean (95% CI) and median (interquartile range) prediction errors were 33.7% (19.8-47.7) and 17.5% (-22.6 to 74.4). A combined data set was created, which included 33 children contributing 310 PK samples. The final improved 2-compartment model included weight and serum creatinine on clearance and oxygenator day and blood transfusion on volume of the central compartment. At an MIC of 8 mg/L, 50 mg/kg/dose every 8 hours reached target concentrations. CONCLUSIONS Dosing intervals of 8 hours were needed to reach adequate concentrations at an MIC of 8 mg/L. Longer dosing intervals were adequate with higher serum creatinine and lower MICs.
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Affiliation(s)
- Céline Thibault
- From the Department of Pediatrics, Division of Critical Care Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Ganesh S Moorthy
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christina Vedar
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine
| | - Mary Ann DiLiberto
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA
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Dubinsky S, Watt K, Saleeb S, Ahmed B, Carter C, Yeung CH, Edginton A. Pharmacokinetics of Commonly Used Medications in Children Receiving Continuous Renal Replacement Therapy: A Systematic Review of Current Literature. Clin Pharmacokinet 2022; 61:189-229. [PMID: 34846703 PMCID: PMC8816883 DOI: 10.1007/s40262-021-01085-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The use of continuous renal replacement therapy (CRRT) for renal support has increased substantially in critically ill children compared with intermittent modalities owing to its preferential effects on hemodynamic stability. With the expanding role of CRRT, the quantification of extracorporeal clearance and the effect on primary pharmacokinetic parameters is of the utmost importance. Within this review, we aimed to summarize the current state of the literature and compare published pharmacokinetic analyses of commonly used medications in children receiving CRRT to those who are not. METHODS A systematic search of the literature within electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science was conducted. Published studies that were included contained relevant information on the use of commonly administered medications to children, from neonates to adolescents, receiving CRRT. Pharmacokinetic parameters that were analyzed included volume of distribution, total clearance, extracorporeal clearance, area under the curve, and elimination half-life. Information regarding CRRT circuit, flow rates, and membrane components was analyzed to investigate differences in pharmacokinetics between each modality. RESULTS Forty-five studies met the final inclusion criteria within this systematic review, totaling 833 pediatric patients, with 586 receiving CRRT. Antimicrobials were the most common pharmacological class represented within the literature, representing 81% (35/43) of studies analyzed. Children receiving CRRT largely had similar volume of distribution and total clearance to critically ill children not receiving CRRT, suggesting reno-protective dose adjustments may lead to subtherapeutic dosing regimens in these patients. Overall, there was a tendency for hydrophilic agents, with a low protein binding to undergo elevated total clearance in these children. However, results should be interpreted with caution because of the large variability amongst patient populations and heterogeneity with CRRT modalities, flow rates, and use of extracorporeal membrane oxygenation within studies. This review was able to identify that variation in solute removal, or CRRT modalities, properties (i.e., flow rates), and membrane composition, may have differing effects on the pharmacokinetics of commonly administered medications. CONCLUSIONS The current state of the literature regarding medications administered to children receiving CRRT largely focuses on antimicrobials. Significant gaps remain with other commonly used medications such as sedatives and analgesics. Overall reporting of patient clinical characteristics, CRRT settings, and circuit composition was poor, with only 10% of articles including all relevant information to assess the impact of CRRT on total clearance. Changes in pharmacokinetics because of CRRT often required higher than labeled doses, suggesting renally adjusted or reno-protective doses may lead to subtherapeutic dosing regimens. A thorough understanding of the interplay between patient, drug, and CRRT-circuit factors are required to ensure adequate delivery of dosing regimens to this vulnerable population.
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Affiliation(s)
- Samuel Dubinsky
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Kevin Watt
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada;,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | | | - Caitlin Carter
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Cindy H.T. Yeung
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
| | - Andrea Edginton
- University of Waterloo, School of Pharmacy, Waterloo, Ontario, Canada
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Darlow CA, da Costa RMA, Ellis S, Franceschi F, Sharland M, Piddock L, Das S, Hope W. Potential Antibiotics for the Treatment of Neonatal Sepsis Caused by Multidrug-Resistant Bacteria. Paediatr Drugs 2021; 23:465-484. [PMID: 34435316 PMCID: PMC8418595 DOI: 10.1007/s40272-021-00465-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 01/26/2023]
Abstract
Neonatal sepsis causes up to an estimated 680,000 deaths annually worldwide, predominantly in low- and middle-income countries (LMICs). A significant and growing proportion of bacteria causing neonatal sepsis are resistant to multiple antibiotics, including the World Health Organization-recommended empiric neonatal sepsis regimen of ampicillin/gentamicin. The Global Antibiotic Research and Development Partnership is aiming to develop alternative empiric antibiotic regimens that fulfil several criteria: (1) affordable in LMIC settings; (2) activity against neonatal bacterial pathogens, including extended-spectrum β-lactamase producers, gentamicin-resistant Gram-negative bacteria, and methicillin-resistant Staphylococcus aureus (MRSA); (3) a licence for neonatal use or extensive experience of use in neonates; and (4) minimal toxicities. In this review, we identify five antibiotics that fulfil these criteria: amikacin, tobramycin, fosfomycin, flomoxef, and cefepime. We describe the available characteristics of each in terms of mechanism of action, resistance mechanisms, clinical pharmacokinetics, pharmacodynamics, and toxicity profile. We also identify some knowledge gaps: (1) the neonatal pharmacokinetics of cefepime is reliant on relatively small and limited datasets, and the pharmacokinetics of flomoxef are also reliant on data from a limited demographic range and (2) for all reviewed agents, the pharmacodynamic index and target has not been definitively established for both bactericidal effect and emergence of resistance, with many assumed to have an identical index/target to similar class molecules. These five agents have the potential to be used in novel combination empiric regimens for neonatal sepsis. However, the data gaps need addressing by pharmacokinetic trials and pharmacodynamic characterisation.
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Affiliation(s)
- Christopher A Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.
| | | | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Laura Piddock
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
- Antimicrobials Research Group, Institute for Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
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10
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McDonald D, Shah P. Cefepime Dosing in Neonates: What is the Evidence? Am J Perinatol 2021; 38:657-661. [PMID: 31777048 DOI: 10.1055/s-0039-3400312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Recommended cefepime dosing strategies in neonates varies in commonly utilized dosing references with regard to dose and frequency. The objective of this review is to summarize and evaluate the available literature describing cefepime dosing in neonatal patients. STUDY DESIGN We performed a literature review in MEDLINE using the keyword cefepime. The search was limited to the English language, humans, and patients <2 months of age. We evaluated four pharmacokinetic studies and two studies describing the use of cefepime in clinical practice. RESULTS The available studies assessing cefepime serum concentrations in neonatal patients demonstrated maintenance of adequate pharmacokinetic parameters when utilizing a dosing frequency of every 12 hours, specifically for organisms with a minimum inhibitory concentration (MIC) ≤ 8 mg/L. In studies evaluating clinical outcomes of cefepime use in neonates, the most frequent adverse effects reported included seizures and hypophosphatemia. Microbiologic cure was demonstrated with a dosing regimen of 50 mg/kg per dose every 12 hours. CONCLUSION Cefepime dosed 30 to 50 mg/kg per dose every 12 hours may be appropriate to achieve a concentration two to four times above an MIC ≤ 8 mg/L for at least 60% of the dosing interval in neonatal patients.
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Affiliation(s)
- Danielle McDonald
- Department of Pharmacy, Cooper University Health Care, 1 Cooper Plaza, Camden, New Jersey
| | - Pooja Shah
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers University, The State University of NJ Piscataway, New Jersey.,Department of Clinical and Pharmacy Services, Hackensack University Medical Center, Hackensack, New Jersey
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11
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Zhao Y, Yao BF, Kou C, Xu HY, Tang BH, Wu YE, Hao GX, Zhang XP, Zhao W. Developmental Population Pharmacokinetics and Dosing Optimization of Cefepime in Neonates and Young Infants. Front Pharmacol 2020; 11:14. [PMID: 32116695 PMCID: PMC7010644 DOI: 10.3389/fphar.2020.00014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/07/2020] [Indexed: 11/13/2022] Open
Abstract
Objective Cefepime is used to treat severe infections in neonates. Pharmacokinetic data have only been evaluated among preterm neonates and population pharmacokinetic model lacked external validation. Hence, our aim is to obtain the population pharmacokinetic parameters of cefepime with large sampling and optimize the cefepime dosage regimen for neonatal infection based on developmental pharmacokinetics–pharmacodynamics. Methods Blood samples from neonates and young infants treated with cefepime were collected using the opportunistic sampling design. The concentration of cefepime was determined using high performance liquid chromatography with ultraviolet detection. The population pharmacokinetic model was established using NONMEM software. Results One hundred blood samples from eighty-five neonates were analyzed. The population pharmacokinetics of cefepime were described by a one-compartment model with first-order elimination. Covariate analysis indicated that serum creatinine concentration, postmenstrual age and current weight had significant impact on the pharmacokinetic parameters of cefepime. Monte Carlo simulation results showed that the current dosage regimen (30 mg/kg, q12 h) had a high risk of insufficient dose. For 70% of neonates to obtain a higher free drug concentration than the minimum inhibitory concentration during 70% of the dosing interval, 50 mg/kg q12 h was needed with a susceptibility breakpoint of 4 mg/l. For a minimum inhibitory concentration of 8 mg/l, 40 mg/kg q8 h was recommended for all neonates. Conclusion A population pharmacokinetic model of cefepime in neonates and young infants was established. According to simulation results based on the developmental pharmacokinetics–pharmacodynamics, different dosage regimens should be given depending on pathogens and the postmenstrual age.
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Affiliation(s)
- Yang Zhao
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Chen Kou
- Department of Neonatology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Hai-Yan Xu
- Department of Neonatology, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Yue-E Wu
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Xin-Ping Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
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12
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Population Pharmacokinetics of Cis-, Trans-, and Total Cefprozil in Healthy Male Koreans. Pharmaceutics 2019; 11:pharmaceutics11100531. [PMID: 31614996 PMCID: PMC6836086 DOI: 10.3390/pharmaceutics11100531] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/23/2019] [Accepted: 10/12/2019] [Indexed: 12/03/2022] Open
Abstract
Cefprozil, one of cephalosporin antibiotics, has been used extensively in clinics. However, pharmacokinetic (PK) information on cefprozil is still very limited. There have been no reports of population pharmacokinetics (PPKs). A PPK model for cefprozil will be a great advantage for clinical use. Thus, the aim of this study was to develop a PPK model for cefprozil for healthy male Koreans. Clinical PK and demographic data of healthy Korean males receiving cefprozil at a dose of 1000 mg were analyzed using Phoenix® NLME™. A one-compartment model with first-order absorption with lag-time was constructed as a base model. The model was extended to include covariates that influenced between-subject variability. Creatinine clearance significantly influenced systemic clearance of cefprozil. The final PPK model for cis-, trans-, and total cefprozil was established and validated. PPK parameter values of cis- and total cefprozil were similar to each other, but different from those of trans-isomer. Herein, we describe the establishment of accurate PPK models of cis-, trans-, and total cefprozil for healthy male Koreans for the first time. It may be useful as a dosing algorithm for the general population. These results might also contribute to the development of stereoisomeric cefprozil.
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13
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Knoderer CA, Kaylor DM, Toth ME, Malloy KM, Nichols KR. Characterization of the Clinical Outcomes With Cefepime in a Neonatal Intensive Care Unit: A Retrospective Cohort Study. J Pediatr Pharmacol Ther 2018; 23:209-214. [PMID: 29970977 PMCID: PMC6027976 DOI: 10.5863/1551-6776-23.3.209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of this study was to characterize clinical outcomes when cefepime was used in a neonatal intensive care population. METHODS Data were extracted from the medical records of all full-term (40 weeks gestational age) patients up to 2 months of age and preterm patients up to 48 weeks postmenstrual age admitted to the neonatal intensive care unit (NICU) at a freestanding children's hospital between January 1, 2010, and December 31, 2013, who received at least 48 hours of cefepime. The primary outcome measure was a positive clinical response as defined by a normalization of white blood cell count and/or culture clearance. RESULTS Final analysis included 74 patients. Clinical response was evaluable in 43.2% (32 of 74) of courses. Of these, positive clinical response was observed in 81.3% (26 of 32). Overall patient mortality was 16.2% (12 of 74). Adverse effects (AEs) occurred in 14.9% (11 of 74) of courses. CONCLUSIONS Cefepime can be used safely with reasonable clinical response in a NICU population, but additional studies are needed to further determine cefepime-associated clinical outcomes.
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14
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Rivera-Chaparro ND, Cohen-Wolkowiez M, Greenberg RG. Dosing antibiotics in neonates: review of the pharmacokinetic data. Future Microbiol 2017; 12:1001-1016. [PMID: 28758800 PMCID: PMC5627030 DOI: 10.2217/fmb-2017-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/23/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are often used in neonates despite the absence of relevant dosing information in drug labels. For neonatal dosing, clinicians must extrapolate data from studies for adults and older children, who have strikingly different physiologies. As a result, dosing extrapolation can lead to increased toxicity or efficacy failures in neonates. Driven by these differences and recent legislation mandating the study of drugs in children and neonates, an increasing number of pharmacokinetic studies of antibiotics are being performed in neonates. These studies have led to new dosing recommendations with particular consideration for neonate body size and maturation. Herein, we highlight the available pharmacokinetic data for commonly used systemic antibiotics in neonates.
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Affiliation(s)
- Nazario D Rivera-Chaparro
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
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15
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Shafiq N, Malhotra S, Gautam V, Kaur H, Kumar P, Dutta S, Ray P, Kshirsagar NA. Evaluation of evidence for pharmacokinetics-pharmacodynamics-based dose optimization of antimicrobials for treating Gram-negative infections in neonates. Indian J Med Res 2017; 145:299-316. [PMID: 28749392 PMCID: PMC5555058 DOI: 10.4103/ijmr.ijmr_723_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND & OBJECTIVES Neonates present a special subgroup of population in whom optimization of antimicrobial dosing can be particularly challenging. Gram-negative infections are common in neonates, and inpatient treatment along with critical care is needed for the management of these infections. Dosing recommendations are often extrapolated from evidence generated in older patient populations. This systematic review was done to identify the knowledge gaps in the pharmacokinetics-pharmacodynamics (PK-PD)-based optimized dosing schedule for parenteral antimicrobials for Gram-negative neonatal infections. METHODS Relevant research questions were identified. An extensive electronic and manual search methodology was used. Potentially eligible articles were screened for eligibility. The relevant data were extracted independently in a pre-specified data extraction form. Pooling of data was planned. RESULTS Of the 340 records screened, 24 studies were included for data extraction and incorporation in the review [carbapenems - imipenem and meropenem (n=7); aminoglycosides - amikacin and gentamicin (n=9); piperacillin-tazobactam (n=2); quinolones (n=2); third- and fourth-generation cephalosporins (n=4) and colistin nil]. For each of the drug categories, the information for all the questions that the review sought to answer was incomplete. There was a wide variability in the covariates assessed, and pooling of results could not be undertaken. INTERPRETATION & CONCLUSIONS There is a wide knowledge gap for determining the doses of antimicrobials used for Gram-negative infections in neonates. A different profile of newborns in the developing countries could affect the disposition of antimicrobials for Gram negative infections, necessitating the generation of PK-PD data of antimicrobials in neonates from developing countries. Further, guidelines for treatment of neonatal conditions may incorporate the evidence-based PK-PD-guided dosing regimens.
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Affiliation(s)
- Nusrat Shafiq
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gautam
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harpreet Kaur
- University School of Business Studies, Punjab University, Chandigarh, India
| | - Pravin Kumar
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sourabh Dutta
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nilima A. Kshirsagar
- National Chair of Clinical Pharmacology, Indian Council of Medical Research, New Delhi, India
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16
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Jonckheere S, De Neve N, De Beenhouwer H, Berth M, Vermeulen A, Van Bocxlaer J, Colin P. A model-based analysis of the predictive performance of different renal function markers for cefepime clearance in the ICU. J Antimicrob Chemother 2016; 71:2538-46. [PMID: 27246236 DOI: 10.1093/jac/dkw171] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 04/12/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Several population pharmacokinetic models for cefepime in critically ill patients have been described, which all indicate that variability in renal clearance is the main determinant of the observed variability in exposure. The main objective of this study was to determine which renal marker best predicts cefepime clearance. METHODS A pharmacokinetic model was developed using NONMEM based on 208 plasma and 51 urine samples from 20 ICU patients during a median follow-up of 3 days. Four serum-based kidney markers (creatinine, cystatin C, urea and uromodulin) and two urinary markers [measured creatinine clearance (CLCR) and kidney injury molecule-1] were evaluated as covariates in the model. RESULTS A two-compartment model incorporating a renal and non-renal clearance component along with an additional term describing haemodialysis clearance provided an adequate description of the data. The Cockcroft-Gault formula was the best predictor for renal cefepime clearance. Compared with the base model without covariates, the objective function value decreased from 1971.7 to 1948.1, the median absolute prediction error from 42.4% to 29.9% and the between-subject variability in renal cefepime clearance from 135% to 50%. Other creatinine- and cystatin C-based formulae and measured CLCR performed similarly. Monte Carlo simulations using the Sanford guide dose recommendations indicated an insufficient dose reduction in patients with a decreased kidney function, leading to potentially toxic levels. CONCLUSIONS The Cockcroft-Gault formula was the best predictor for cefepime clearance in critically ill patients, although other creatinine- and cystatin C-based formulae and measured CLCR performed similarly.
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Affiliation(s)
- Stijn Jonckheere
- Clinical Laboratory of Microbiology, OLVZ Aalst, Moorselbaan 164, 9300 Aalst, Belgium
| | - Nikolaas De Neve
- Department of Critical Care Medicine, OLVZ Aalst, Moorselbaan 164, 9300 Aalst, Belgium
| | - Hans De Beenhouwer
- Clinical Laboratory of Microbiology, OLVZ Aalst, Moorselbaan 164, 9300 Aalst, Belgium
| | - Mario Berth
- Department of Immunology, Algemeen Medisch Laboratorium, Emiel Vloorsstraat 9, 2020 Antwerp, Belgium
| | - An Vermeulen
- Laboratory for Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Harelbekestraat 72, 9000 Ghent, Belgium
| | - Jan Van Bocxlaer
- Laboratory for Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Harelbekestraat 72, 9000 Ghent, Belgium
| | - Pieter Colin
- Laboratory for Medical Biochemistry and Clinical Analysis, Faculty of Pharmaceutical Sciences, Ghent University, Harelbekestraat 72, 9000 Ghent, Belgium Department of Anaesthesiology, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
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17
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Wilbaux M, Fuchs A, Samardzic J, Rodieux F, Csajka C, Allegaert K, van den Anker JN, Pfister M. Pharmacometric Approaches to Personalize Use of Primarily Renally Eliminated Antibiotics in Preterm and Term Neonates. J Clin Pharmacol 2016; 56:909-35. [PMID: 26766774 DOI: 10.1002/jcph.705] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 12/13/2022]
Abstract
Sepsis remains a major cause of mortality and morbidity in neonates, and, as a consequence, antibiotics are the most frequently prescribed drugs in this vulnerable patient population. Growth and dynamic maturation processes during the first weeks of life result in large inter- and intrasubject variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics. In this review we (1) summarize the available population PK data and models for primarily renally eliminated antibiotics, (2) discuss quantitative approaches to account for effects of growth and maturation processes on drug exposure and response, (3) evaluate current dose recommendations, and (4) identify opportunities to further optimize and personalize dosing strategies of these antibiotics in preterm and term neonates. Although population PK models have been developed for several of these drugs, exposure-response relationships of primarily renally eliminated antibiotics in these fragile infants are not well understood, monitoring strategies remain inconsistent, and consensus on optimal, personalized dosing of these drugs in these patients is absent. Tailored PK/PD studies and models are useful to better understand relationships between drug exposures and microbiological or clinical outcomes. Pharmacometric modeling and simulation approaches facilitate quantitative evaluation and optimization of treatment strategies. National and international collaborations and platforms are essential to standardize and harmonize not only studies and models but also monitoring and dosing strategies. Simple bedside decision tools assist clinical pharmacologists and neonatologists in their efforts to fine-tune and personalize the use of primarily renally eliminated antibiotics in term and preterm neonates.
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Affiliation(s)
- Mélanie Wilbaux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Aline Fuchs
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Janko Samardzic
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Institute of Pharmacology, Clinical Pharmacology and Toxicology, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Frédérique Rodieux
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Chantal Csajka
- Division of Clinical Pharmacology, Service of Biomedicine, Department of Laboratory, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Belgium.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Johannes N van den Anker
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Marc Pfister
- Division of Paediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland.,Quantitative Solutions LP, Menlo Park, CA, USA
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18
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Population Pharmacokinetic Assessment and Pharmacodynamic Implications of Pediatric Cefepime Dosing for Susceptible-Dose-Dependent Organisms. Antimicrob Agents Chemother 2016; 60:2150-6. [PMID: 26810655 DOI: 10.1128/aac.02592-15] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 01/16/2016] [Indexed: 11/20/2022] Open
Abstract
The Clinical and Laboratory Standards Institute (CLSI) revised cefepime (CFP) breakpoints forEnterobacteriaceaein 2014, and MICs of 4 and 8 μg/ml were reclassified as susceptible-dose dependent (SDD). Pediatric dosing to provide therapeutic concentrations against SDD organisms has not been defined. CFP pharmacokinetics (PK) data from published pediatric studies were analyzed. Population PK parameters were determined using NONMEM, and Monte Carlo simulation was performed to determine an appropriate CFP dosage regimen for SDD organisms in children. A total of 664 CFP plasma concentrations from 91 neonates, infants, and children were included in this analysis. The median patient age was 1.0 month (interquartile range [IQR], 0.2 to 11.2 months). Serum creatinine (SCR) and postmenstrual age (PMA) were covariates in the final PK model. Simulations indicated that CFP dosing at 50 mg/kg every 8 h (q8h) (as 0.5-h intravenous [i.v.] infusions) will maintain free-CFP concentrations in serum of >4 and 8 μg/ml for >60% of the dose interval in 87.1% and 68.6% of pediatric patients (age, ≥30 days), respectively, and extending the i.v. infusion duration to 3 h results in 92.3% of patients with free-CFP levels above 8 μg/ml for >60% of the dose interval. CFP clearance (CL) is significantly correlated with PMA and SCR. A dose of 50 mg/kg of CFP every 8 to 12 h does not achieve adequate serum exposure for older children with serious infections caused by Gram-negative bacilli with a MIC of 8 μg/ml. Prolonged i.v. infusions may be useful for this population.
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19
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Marsot A, Boulamery A, Bruguerolle B, Simon N. Population pharmacokinetic analysis during the first 2 years of life: an overview. Clin Pharmacokinet 2013. [PMID: 23179579 DOI: 10.1007/s40262-012-0015-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Three decades after its introduction, pharmacokinetic population approaches have become a reference method for drug modelling, particularly in paediatrics. The main practical limitation in this specific population is the collected blood volume. Pharmacokinetic population approaches using sparse sampling may resolve this issue. The pharmacokinetics of many drugs have been studied during the last 25 years using such methods. This review summarizes all of the published studies concerning population pharmacokinetic approaches in paediatric subjects from neonate to 2 years old. A literature search was conducted using the PubMed database, from 1985 to December 2010, using the following terms: pharmacokinetic(s), population, paediatric/pediatric and neonate(s). Articles were excluded if they were not pertinent according to our criteria. References of all relevant articles were also evaluated. Ninety-eight studies were included in this review. The following information was extracted from the articles: drug name, therapeutic class, population size, age of patients, number of samples per patient, covariates used for clearance and volume of distribution estimates, software used for modelling and validation methods. An increasing rate of publications over the years was observed; 44 different drugs were studied using a pharmacokinetic population approach. Antibacterials were the most studied class of drugs, including a large number of studies devoted to vancomycin and gentamicin. It must be underlined that few studies have been performed on anticonvulsant drugs and anaesthetics used in clinical daily practice conditions.
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Affiliation(s)
- Amélie Marsot
- Service de Pharmacologie Médicale et Clinique, Aix Marseille Université, France.
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20
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Abstract
The aim of this work was to review the published data on the pharmacokinetics of cephalosporins in neonates to provide a critical analysis of the literature as a useful tool for physicians. The bibliographic search was performed for articles published up to December 3, 2010, using PubMed. In addition, the book Neofax: A Manual of Drugs Used in Neonatal Care by Young and Mangum was consulted. The cephalosporins are mainly eliminated by the kidneys, and their elimination rates are reduced at birth. As a consequence, clearance is reduced and t1/2 is more prolonged in the neonate than in more mature infants. The neonate's substantial body water content creates a large volume of distribution (Vd) of cephalosporins, as these drugs are fairly water soluble. Postnatal development is an important factor in the maturation of the neonate, and as postnatal age proceeds, the clearance of cephalosporins increases. The maturation of the kidney governs the pharmacokinetics of cephalosporins in the infant. Clearance and t1/2 are influenced by development, and this must be taken into consideration when planning a cephalosporin dosage regimen for the neonate.
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Affiliation(s)
- Gian Maria Pacifici
- Section of Pharmacology, Department of Neurosciences, Medical School, University of Pisa, Pisa, Italy.
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21
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Pacifici GM. Clinical Pharmacokinetics of Penicillins, Cephalosporins and Aminoglycosides in the Neonate: A Review. Pharmaceuticals (Basel) 2010; 3:2568-2591. [PMID: 27713367 PMCID: PMC4033939 DOI: 10.3390/ph3082568] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 07/22/2010] [Accepted: 08/03/2010] [Indexed: 11/16/2022] Open
Abstract
Bacterial infections are common in the neonates and are a major cause of morbidity and mortality. Sixty percent of preterm infants admitted to neonatal intensive care units received at least one antibiotic during the first week of life. Penicillins, aminoglycosides and cephalosporins comprised 53, 43 and 16%, respectively. Kinetic parameters such as the half-life (t1/2), clearance (Cl), and volume of distribution (Vd) change with development, so the kinetics of penicillins, cephalosporins and aminoglycosides need to be studied in order to optimise therapy with these drugs. The aim of this study is to review the pharmacokinetics of penicillins, cephalosporins and aminoglycosides in the neonate in a single article in order to provide a critical analysis of the literature and thus provide a useful tool in the hands of physicians. The bibliographic search was performed electronically using PubMed, as the search engine, until February 2nd, 2010. Medline search terms were as follows: pharmacokinetics AND (penicillins OR cephalosporins OR aminoglycosides) AND infant, newborn, limiting to humans. Penicillins, cephalosporins and aminoglycosides are fairly water soluble and are mainly eliminated by the kidneys. The maturation of the kidneys governs the pharmacokinetics of penicillins, cephalosporins and aminoglycosides in the neonate. The renal excretory function is reduced in preterms compared to term infants and Cl of these drugs is reduced in premature infants. Gestational and postnatal ages are important factors in the maturation of the neonate and, as these ages proceed, Cl of penicillins, cephalosporins and aminoglycosides increases. Cl and t1/2 are influenced by development and this must be taken into consideration when planning a dosage regimen with these drugs. More pharmacokinetic studies are required to ensure that the dose recommended for the treatment of sepsis in the neonate is evidence based.
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Affiliation(s)
- Gian Maria Pacifici
- Section of Pharmacology, Department of Neurosciences, Medical School, University of Pisa, Via Roma 55, 56126 Pisa, Italy.
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22
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Population pharmacokinetics of high-dose, prolonged-infusion cefepime in adult critically ill patients with ventilator-associated pneumonia. Antimicrob Agents Chemother 2009; 53:1476-81. [PMID: 19188394 DOI: 10.1128/aac.01141-08] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A population pharmacokinetic model of cefepime was constructed from data from adult critical care patients with ventilator-associated pneumonia (VAP). A total of 32 patients treated with high-dose cefepime, 2 g every 8 h (3-h infusion) or a renal function-adjusted equivalent dose, were randomized into two groups--26 for the initial model and 6 for model validation. Serum samples of cefepime were collected at steady state. Nonparametric adaptive grid population modeling was employed using a two-compartment K(slope) pharmacokinetic model relating the elimination rate constant (K(10)) to renal function, as defined by creatinine clearance (CL(CR)), and central distribution volume (V(1)) to total body weight (TBW). The final model was described by the following equations: K(10) = 0.0027 x CL(CR) + 0.071 h(-1) and V(1) = TBW x 0.21 liter/kg. The median intercompartmental transfer constants K(12) and K(21) were 0.780 h(-1) and 0.472 h(-1), respectively. Using these median parameter estimates, the bias, precision, and coefficient of determination for the initial model were 11.3 microg/ml, 24.0 microg/ml, and 26%, respectively. The independent validation group displayed a bias, precision, and coefficient of determination of -1.64 microg/ml, 17.1 microg/ml, and 62%, respectively. Time-concentration profiles were assessed for various dosing regimens, using 5,000-patient Monte Carlo simulations. Among the regimens, the likelihoods of 2 g every 8 h (3-h infusion) achieving free drug concentrations above the MIC for 50% of the dosing interval were 91.8%, 78.1%, and 50.3% for MICs of 8, 16, and 32 microg/ml, respectively. This study provides a pharmacokinetic model capable of predicting cefepime concentrations in critically ill patients with VAP.
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Endimiani A, Perez F, Bonomo RA. Cefepime: a reappraisal in an era of increasing antimicrobial resistance. Expert Rev Anti Infect Ther 2008; 6:805-24. [PMID: 19053894 PMCID: PMC2633657 DOI: 10.1586/14787210.6.6.805] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cefepime is a 'fourth-generation' cephalosporin with an in vitro extended-spectrum of activity against Gram-negative and Gram-positive pathogens. Cefepime is approved for the treatment of moderate-to-severe infections, such as pneumonia, uncomplicated and complicated urinary tract infections, skin and soft-tissue infections, intra-abdominal infections and febrile neutropenia. In this article, we provide a critical review of pharmacodynamics, clinical management, pharmacokinetics, metabolism, pharmacodynamic target analyses, clinical efficacy, safety and tolerability of cefepime after more than a decade of clinical use.
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Affiliation(s)
- Andrea Endimiani
- Department of Medicine, Section of Infectious Diseases, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
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