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Oda K, Yamada T, Matsumoto K, Hanai Y, Ueda T, Samura M, Shigemi A, Jono H, Saito H, Kimura T. Model-informed precision dosing of vancomycin for rapid achievement of target area under the concentration-time curve: A simulation study. Clin Transl Sci 2023; 16:2265-2275. [PMID: 37718491 PMCID: PMC10651648 DOI: 10.1111/cts.13626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/19/2023] Open
Abstract
In this study, we aimed to evaluate limited sampling strategies for achieving the therapeutic ranges of the area under the concentration-time curve (AUC) of vancomycin on the first and second day (AUC0-24 , AUC24-48 , respectively) of therapy. A virtual population of 1000 individuals was created using a population pharmacokinetic (PopPK) model, which was validated and incorporated into our model-informed precision dosing tool. The results were evaluated using six additional PopPK models selected based on a study design of prospective or retrospective data collection with sufficient concentrations. Bayesian forecasting was performed to evaluate the probability of achieving the therapeutic range of AUC, defined as a ratio of estimated/reference AUC within 0.8-1.2. The Bayesian posterior probability of achieving the AUC24-48 range increased from 51.3% (a priori probability) to 77.5% after using two-point sampling at the trough and peak on the first day. Sampling on the first day also yielded a higher Bayesian posterior probability (86.1%) of achieving the AUC0-24 range compared to the a priori probability of 60.1%. The Bayesian posterior probability of achieving the AUC at steady-state (AUCSS ) range by sampling on the first or second day decreased with decreased kidney function. We demonstrated that second-day trough and peak sampling provided accurate AUC24-48 , and first-day sampling may assist in rapidly achieving therapeutic AUC24-48 , although the AUCSS should be re-estimated in patients with reduced kidney function owing to its unreliable predictive performance.
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Affiliation(s)
- Kazutaka Oda
- Department of PharmacyKumamoto University HospitalKumamotoJapan
- Department of Infection ControlKumamoto University HospitalKumamotoJapan
| | - Tomoyuki Yamada
- Department of PharmacyOsaka Medical and Pharmaceutical University HospitalOsakaJapan
| | - Kazuaki Matsumoto
- Division of PharmacodynamicsKeio University Faculty of PharmacyTokyoJapan
| | - Yuki Hanai
- Department of Clinical Pharmacy, Faculty of Pharmaceutical SciencesToho UniversityChibaJapan
| | - Takashi Ueda
- Department of Infection Control and PreventionHyogo College of MedicineNishinomiyaHyogoJapan
| | - Masaru Samura
- Department of PharmacyYokohama General HospitalYokohamaKanagawaJapan
| | - Akari Shigemi
- Department of PharmacyKagoshima University HospitalKagoshima CityKagoshimaJapan
| | - Hirofumi Jono
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Hideyuki Saito
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Toshimi Kimura
- Department of PharmacyJuntendo University HospitalTokyoJapan
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2
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Oommen T, Thommandram A, Palanica A, Fossat Y. A Free Open-Source Bayesian Vancomycin Dosing App for Adults: Design and Evaluation Study. JMIR Form Res 2022; 6:e30577. [PMID: 35353046 PMCID: PMC9008526 DOI: 10.2196/30577] [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: 05/20/2021] [Revised: 10/08/2021] [Accepted: 02/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background It has been suggested that Bayesian dosing apps can assist in the therapeutic drug monitoring of patients receiving vancomycin. Unfortunately, Bayesian dosing tools are often unaffordable to resource-limited hospitals. Our aim was to improve vancomycin dosing in adults. We created a free and open-source dose adjustment app, VancoCalc, which uses Bayesian inference to aid clinicians in dosing and monitoring of vancomycin. Objective The aim of this paper is to describe the design, development, usability, and evaluation of a free open-source Bayesian vancomycin dosing app, VancoCalc. Methods The app build and model fitting process were described. Previously published pharmacokinetic models were used as priors. The ability of the app to predict vancomycin concentrations was performed using a small data set comprising of 52 patients, aged 18 years and over, who received at least 1 dose of intravenous vancomycin and had at least 2 vancomycin concentrations drawn between July 2018 and January 2021 at Lakeridge Health Corporation Ontario, Canada. With these estimated and actual concentrations, median prediction error (bias), median absolute error (accuracy), and root mean square error (precision) were calculated to evaluate the accuracy of the Bayesian estimated pharmacokinetic parameters. Results A total of 52 unique patients’ initial vancomycin concentrations were used to predict subsequent concentration; 104 total vancomycin concentrations were assessed. The median prediction error was –0.600 ug/mL (IQR –3.06, 2.95), the median absolute error was 3.05 ug/mL (IQR 1.44, 4.50), and the root mean square error was 5.34. Conclusions We described a free, open-source Bayesian vancomycin dosing calculator based on revisions of currently available calculators. Based on this small retrospective preliminary sample of patients, the app offers reasonable accuracy and bias, which may be used in everyday practice. By offering this free, open-source app, further prospective validation could be implemented in the near future.
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Affiliation(s)
| | | | - Adam Palanica
- Klick Applied Sciences, Klick Health, Klick Inc, Toronto, ON, Canada
| | - Yan Fossat
- Klick Applied Sciences, Klick Health, Klick Inc, Toronto, ON, Canada
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3
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Ohata K, Kitagawa J, Niwa T, Takahashi-Yamauchi T, Harada S, Matsumoto T, Nakamura N, Nakamura H, Kanemura N, Shimizu M, Suzuki A. Comparison of breakthrough Gram-positive cocci infection during vancomycin vs teicoplanin therapy in patients receiving haematopoietic stem cell transplantation. J Clin Pharm Ther 2020; 45:1342-1348. [PMID: 32656902 DOI: 10.1111/jcpt.13215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/18/2020] [Accepted: 06/09/2020] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Our previous report indicated that teicoplanin (TEIC) caused fewer adverse effects than vancomycin (VCM) in patients with febrile neutropenia (FN) receiving haematopoietic stem cell transplantation (HSCT). However, we observed breakthrough methicillin-resistant-Staphylococcus haemolyticus (MR-S haemolyticus) infection during TEIC therapy in these patients. In this study, we sought to compare the incidence of breakthrough Gram-positive cocci (GPC) infection during VCM and TEIC therapy in this population. METHODS A single-centre, retrospective cohort study was conducted. Patients who had received HSCT and were administered VCM (n = 19) or TEIC (n = 38) for FN from 1 September 2011 to 31 August 2019 were enrolled. We compared the incidence of breakthrough GPC infection between the VCM and TEIC groups. RESULTS Breakthrough GPC infection during glycopeptide therapy in febrile neutropenic patients received HSCT was observed in three patients (7.9%) in the TEIC group but in none of patients (0%) in the VCM group. MR-S haemolyticus with low glycopeptide susceptibility (TEIC MIC = 2-8 μg/mL, VCM MIC = 2-4 μg/mL) was isolated from blood cultures in all patients with breakthrough GPC infections. All breakthrough infections were cured by changing from TEIC to daptomycin (DAP). WHAT IS NEW AND CONCLUSION The incidence of breakthrough GPC infection during glycopeptide therapy in febrile neutropenic HSCT patients was higher in the TEIC group than in the VCM group. MR-S haemolyticus with low glycopeptide susceptibility was isolated from all patients with breakthrough GPC infection and successfully treated with DAP.
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Affiliation(s)
- Koichi Ohata
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Junichi Kitagawa
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takashi Niwa
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | | | - Saki Harada
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Takuro Matsumoto
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuhiko Nakamura
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroshi Nakamura
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuhiro Kanemura
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
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Kato-Hayashi H, Niwa T, Ohata K, Harada S, Matsumoto T, Kitagawa J, Tsurumi H, Suzuki A. Comparative efficacy and safety of vancomycin versus teicoplanin in febrile neutropenic patients receiving hematopoietic stem cell transplantation. J Clin Pharm Ther 2019; 44:888-894. [PMID: 31373043 DOI: 10.1111/jcpt.13011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/28/2019] [Accepted: 07/08/2019] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Patients who receive hematopoietic stem cell transplantation (HSCT) are usually administered a calcineurin inhibitor. Because vancomycin is associated with an increased incidence of nephrotoxicity, neutropenic patients receiving HSCT are considered a high-risk population for nephrotoxicity with vancomycin. We retrospectively compared the efficacy and safety of vancomycin and teicoplanin in febrile neutropenic patients receiving HSCT. METHODS A single-centre, retrospective cohort study was conducted at the 614-bed Gifu University Hospital in Japan. Patients who received HSCT and were administered vancomycin or teicoplanin by injection for febrile neutropenia from 1 January 2012 to 31 August 2017 were enrolled. Time to attain an effective trough concentration, clinical efficacy and adverse events were compared between the two groups. RESULTS Time to attain an effective trough concentration of over 10 μg/mL tended to be shorter in the teicoplanin group than in the vancomycin group (median 3, 95% confidence interval [CI] 2.4-3.6 days vs median 6, 95% CI 1.5-10.5 days; hazard ratio [HR] 0.4, 95% CI 0.15-1.06; P = .066). The rate of clinical failure was lower in the teicoplanin group than in the vancomycin group (18.8% vs 53.8%, P = .113). In addition, the overall incidence of nephrotoxicity was significantly lower in the teicoplanin group (0% vs 46.2%, P = .004). WHAT IS NEW AND CONCLUSION Our findings suggest that administration of teicoplanin may lead to early attainment of the effective concentration with a lower rate of clinical failure and incidence of nephrotoxicity compared to vancomycin in febrile neutropenic patients receiving HSCT.
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Affiliation(s)
| | - Takashi Niwa
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Koichi Ohata
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Saki Harada
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Takuro Matsumoto
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Junichi Kitagawa
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hisashi Tsurumi
- First Department of Internal Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
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5
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Chuma M, Makishima M, Imai T, Tochikura N, Suzuki S, Kuwana T, Sawada N, Iwabuchi S, Sekimoto M, Nakayama T, Sakaue T, Kikuchi N, Yoshida Y, Kinoshita K. Relationship between hemoglobin levels and vancomycin clearance in patients with sepsis. Eur J Clin Pharmacol 2019; 75:929-937. [PMID: 30868193 DOI: 10.1007/s00228-019-02661-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/03/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE It is important to accurately estimate accurate vancomycin (VCM) clearance (CLvcm) for appropriate VCM dosing in the treatment of patients with sepsis. However, the pathophysiology of sepsis can make CLvcm prediction less accurate. Clearance of hydrophilic antibiotics is disturbed by organ dysfunction, and hemoglobin levels are negatively correlated with sequential organ function assessment scores. We investigated whether hemoglobin levels are associated with CLvcm in sepsis patients. METHODS We performed a retrospective cohort study of patients treated with VCM in the Emergency and Critical Care Center of Nihon University Itabashi Hospital between 2005 and 2015. We enrolled 72 patients after exclusion of patients who received renal replacement therapy or surgery, had a change in hemoglobin levels more than 2 g/dL or received an erythrocyte infusion during the interval between initial VCM administration and measurement of initial trough levels, had a serum baseline creatinine level of ≥ 2 mg/dL, or were under 18 years old. RESULTS Enrolled patients consisted of 13 non-sepsis patients and 59 sepsis patients. In sepsis patients, although CLvcm was correlated with CrCl in HGB ≥ 9 group as well as in non-sepsis patients, its correlation was not observed in HGB < 9 group. Hemoglobin levels were correlated with CLvcm in sepsis patients but not in non-sepsis patient. Multiple linear regression analysis also indicated that lower CLvcm was associated with lower hemoglobin and CrCl. CONCLUSION Lower hemoglobin levels influence a relationship between CLvcm and CrCl in sepsis patients. We propose that VCM dosing should be adjusted for hemoglobin levels in sepsis patients.
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Affiliation(s)
- Masayuki Chuma
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan.,Clinical Trial Center for Developmental Therapeutics, Tokushima University Hospital, 2-50-1 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Makoto Makishima
- Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Toru Imai
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Naohiro Tochikura
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Shinichiro Suzuki
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Tsukasa Kuwana
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Nami Sawada
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - So Iwabuchi
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Masao Sekimoto
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takahiro Nakayama
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takako Sakaue
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | | | - Yoshikazu Yoshida
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
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Relationship Between Initial Vancomycin Trough Levels and Early-Onset Vancomycin-Associated Nephrotoxicity in Critically Ill Patients. Ther Drug Monit 2018; 40:109-114. [PMID: 29095798 DOI: 10.1097/ftd.0000000000000459] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Appropriate initial dosing of vancomycin (VCM) is important in improving survival and in preventing nephrotoxicity in critically ill patients, but the potential relationship between initial VCM trough levels and early-onset nephrotoxicity remains unclear. We examined the relationship between initial VCM trough levels and early-onset VCM-associated nephrotoxicity. METHODS We performed a retrospective study of patients who had therapeutic drug monitoring of VCM with initial trough levels within 4 days after the beginning of VCM administration. We excluded patients who received renal replacement therapy from 2 days before to 7 days after the beginning of VCM administration, were younger than 18 years, or had renal dysfunction before the beginning of VCM administration. Early-onset VCM-associated nephrotoxicity was defined as an increase in serum creatinine level of ≥0.5 mg/dL (44.2 μmol/L) or 50% above baseline for 2 or more consecutive days within 7 days after the beginning of VCM administration. RESULTS Among 109 enrolled patients, 13 patients had early-onset VCM-associated nephrotoxicity. Its incidence rate was 31.3% in patients with initial trough levels of ≥20g/mL, which was significantly higher than 6.3% in patients with initial trough levels of <10 mg/L. Multiple logistic regression analysis demonstrated that early-onset VCM-associated nephrotoxicity was associated with initial trough levels of ≥20 mg/L (odds ratio, 5.0; 95% confidence interval, 1.3-19.1) and with vasopressor use (odds ratio, 5.0; 95% confidence interval, 1.3-19.1). Kaplan-Meier analysis showed that the probability of nonnephrotoxicity for patients with initial VCM trough levels of ≥20 mg/L was lower compared with patients with trough levels of <15 mg/L. CONCLUSIONS Initial trough levels of ≥20 mg/L but not ≥15 mg/L were associated with early-onset VCM-associated nephrotoxicity in critically ill patients. Future prospective studies are needed to examine outcomes in critically ill patients achieving initial VCM trough levels of 15-20 mg/L.
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7
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Monteiro JF, Hahn SR, Gonçalves J, Fresco P. Vancomycin therapeutic drug monitoring and population pharmacokinetic models in special patient subpopulations. Pharmacol Res Perspect 2018; 6:e00420. [PMID: 30156005 PMCID: PMC6113434 DOI: 10.1002/prp2.420] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 06/20/2018] [Indexed: 01/02/2023] Open
Abstract
Vancomycin is a fundamental antibiotic in the management of severe Gram-positive infections. Inappropriate vancomycin dosing is associated with therapeutic failure, bacterial resistance and toxicity. Therapeutic drug monitoring (TDM) is acknowledged as an important part of the vancomycin therapy management, at least in specific patient subpopulations, but implementation in clinical practice has been difficult because there are no consensus and agglutinator documents. The aims of the present work are to present an overview of the current knowledge on vancomycin TDM and population pharmacokinetic (PPK) models relevant to specific patient subpopulations. Based on three published international guidelines (American, Japanese and Chinese) on vancomycin TDM and a bibliographic review on available PPK models for vancomycin in distinct subpopulations, an analysis of evidence was carried out and the current knowledge on this topic was summarized. The results of this work can be useful to redirect research efforts to address the detected knowledge gaps. Currently, TDM of vancomycin presents a moderate level of evidence and practical recommendations with great robustness in neonates, pediatric and patients with renal impairment. However, it is important to investigate in other subpopulations known to present altered vancomycin pharmacokinetics (eg neurosurgical, oncological and cystic fibrosis patients), where evidence is still unsufficient.
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Affiliation(s)
- Joaquim F. Monteiro
- Faculdade de Medicina da Universidade do Porto (FMUP)PortoPortugal
- Instituto de Investigação e Formação Avançadas em Ciências e Tecnologias da Saúde (IINFACTS)Instituto Universitário de Ciências da Saúde (IUCS)GandraPortugal
| | - Siomara R. Hahn
- Instituto de Ciências BiológicasCurso de FarmáciaUniversidade de Passo Fundo (UPF)Passo FundoBrasil
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
| | - Jorge Gonçalves
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
| | - Paula Fresco
- Laboratório de FarmacologiaDepartamento de Ciências do MedicamentoFaculdade de Farmácia da Universidade do Porto (FFUP)PortoPortugal
- I3SInstituto de Investigação e Inovação em SaúdeUniversidade do PortoPortoPortugal
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8
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Chuma M, Makishima M, Imai T, Tochikura N, Sakaue T, Kikuchi N, Kinoshita K, Kaburaki M, Yoshida Y. Duration of Systemic Inflammatory Response Syndrome Influences Serum Vancomycin Concentration in Patients With Sepsis. Clin Ther 2016; 38:2598-2609. [PMID: 27836495 DOI: 10.1016/j.clinthera.2016.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/13/2016] [Accepted: 10/19/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Vancomycin (VCM) is used in the treatment of methicillin-resistant Staphylococcus aureus infection. The dosage of VCM must be adjusted by using therapeutic drug monitoring because of the drug's narrow therapeutic concentration window. Although optimal administration based on population pharmacokinetic (PPK) analysis and/or a Bayesian method has improved prediction accuracy, serum concentrations of VCM in patients with sepsis often deviate significantly from predicted values. We investigated factors influencing prediction errors with PPK analysis in VCM dosing. METHODS This retrospective cohort study included patients treated with VCM. Their clinical data were recorded, and there were 27 nonseptic patients and 68 septic patients. VCM concentrations were predicted by using PPK analysis and data compared with observed concentrations. FINDINGS Patients with sepsis had a higher mean absolute error than nonseptic patients, indicating a deviation of VCM concentrations from predicted values in the septic patients. To determine factors influencing prediction errors, we classified patients with sepsis into 3 subgroups according to the mean absolute error value (2.17) for the nonseptic patients: "lower" group (prediction errors, below -2.17), "upper" group (>2.17), and "no change" group (-2.17 to 2.17). In a comparison of clinical characteristics of the 3 groups, significant differences were found in the duration of systemic inflammatory response syndrome (SIRS), SIRS score, disseminated intravascular coagulation score, and levels of creatinine clearance (CrCl), hemoglobin, and diastolic blood pressure. Multiple logistic regression analysis identified SIRS duration and CrCl as factors associated with VCM concentrations in the lower and/or upper groups of septic patients. Shorter and longer SIRS duration were associated with VCM concentrations in the lower group and the upper group, respectively, compared with predicted values in patients with sepsis. According to receiver-operating characteristic curve analysis, the optimal cutoff value of SIRS duration for the lower group was 2 days; for the upper group, it was 6 days. VCM clearance in patients with an SIRS duration <2 days was higher than that for patients with an SIRS duration ≥6 days. IMPLICATIONS SIRS duration was identified as influencing VCM concentration in patients with sepsis. This study has 2 limitations. First, we performed blood sampling only for trough concentrations. Repeated blood sampling for both peak and trough concentrations should be performed for more accurate pharmacokinetic evaluation in critically ill patients. Second, we determined CrCl by using the Cockcroft-Gault formula, which may not be accurate in critically ill patients. Modifying VCM dosing according to SIRS duration will improve prediction accuracy of VCM concentration based on therapeutic drug monitoring.
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Affiliation(s)
- Masayuki Chuma
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Makoto Makishima
- Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, Tokyo, Japan.
| | - Toru Imai
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Naohiro Tochikura
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Takako Sakaue
- Department of Pharmacy, Kanagawa Prefectural Keiyukai Keiyu Hospital, Yokohama, Japan
| | | | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Morio Kaburaki
- Department of Pharmacy, Nihon University Hospital, Tokyo, Japan
| | - Yoshikazu Yoshida
- Department of Pharmacy, Nihon University Itabashi Hospital, Tokyo, Japan
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9
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Fukumori S, Tsuji Y, Mizoguchi A, Kasai H, Ishibashi T, Iwamura N, To H. Association of the clinical efficacy of vancomycin with the novel pharmacokinetic parameter area under the trough level (AUTL) in elderly patients with hospital-acquired pneumonia. J Clin Pharm Ther 2016; 41:399-402. [PMID: 27144370 DOI: 10.1111/jcpt.12399] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 04/08/2016] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The pharmacokinetic-pharmacodynamic parameter that best predicts the efficacy of vancomycin is the ratio of the area under the concentration versus time curve (AUC) to the minimum inhibitory concentration (MIC). A 24-h AUC (AUC24 )/MIC ratio ≥ 400 was recommended in an American consensus review, but vancomycin treatment occasionally fails despite maintenance of AUC24 /MIC ≥ 400. We evaluated the association between clinical efficacy of vancomycin and two novel pharmacokinetic parameters, the 'area under the trough level' (AUTL) and the 'area above the trough level' (AATL), in hospitalized elderly patients with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. METHODS The subjects were hospitalized elderly patients who were administered vancomycin for treatment of MRSA pneumonia between 2006 and 2012 at Sasebo Chuo Hospital (Nagasaki, Japan). Pharmacokinetic parameters of vancomycin were estimated for each patient by Bayesian analysis using population pharmacokinetic parameters for Japanese patients. Based on the patient-specific parameters thus obtained, AUC24 values were calculated as the vancomycin dosage divided by vancomycin clearance. AUTL was calculated as the trough serum concentration multiplied by 24 h, whereas AATL was calculated by subtracting AUTL from AUC24 . RESULTS AND DISCUSSION Logistic regression analysis demonstrated that efficacy of vancomycin was more strongly associated with AUTL than AUC24 . The optimal cut-off value of AUTL was 331 μg∙h/mL, which means that the optimal cut-off value of the trough serum concentration was 13·8 μg/mL. WHAT IS NEW AND CONCLUSION Efficacy of vancomycin was associated with AUTL, a novel pharmacokinetic parameter. Determining the target AUTL or trough concentration may enhance the efficacy of vancomycin therapy in elderly patients with MRSA pneumonia. Given that nephrotoxicity may increase with a Ctrough in excess of 15 μg/mL, this level should ideally not be exceeded.
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Affiliation(s)
- S Fukumori
- Department of Community Pharmacy, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Y Tsuji
- Department of Medical Pharmaceutics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - A Mizoguchi
- Department of Pharmacy, Sasebo Chuo Hospital, Sasebo, Japan
| | - H Kasai
- Department of Medical Pharmaceutics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan.,Certara G.K., Minato-ku, Tokyo, Japan
| | - T Ishibashi
- Department of Medical Pharmaceutics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan.,Shionogi Research Laboratories, Osaka, Japan
| | - N Iwamura
- Department of Pharmacy, Sasebo Chuo Hospital, Sasebo, Japan
| | - H To
- Department of Medical Pharmaceutics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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10
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Nunn MO, Corallo CE, Aubron C, Poole S, Dooley MJ, Cheng AC. Vancomycin Dosing: Assessment of Time to Therapeutic Concentration and Predictive Accuracy of Pharmacokinetic Modeling Software. Ann Pharmacother 2011; 45:757-63. [DOI: 10.1345/aph.1p634] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: Therapeutic drug monitoring is usually required for safe and effective administration of vancomycin. However, dosing recommendations from published guidelines are not suitable in achieving therapeutic vancomycin concentrations in a timely manner in patients with normal renal function. OBJECTIVE: To audit vancomycin dosing and concentrations at our institution and evaluate the predictive accuracy of a pharmacokinetic simulation program, with a view to implementing a pharmacy-based pharmacokinetic service for vancomycin monitoring. METHODS: Patients receiving vancomycin were identified prospectively through the therapeutic drug monitoring archives. Patient information was obtained from medication charts and medical records that were located on wards. Data were entered into the MM-USC*Pack program (Jelliffe R, University of Southern California, 2008, version 12.10). This software was used to predict initial and subsequent concentrations of vancomycin based on patient parameters. The predictive accuracy of this software was evaluated by comparing the predicted concentrations to the observed concentrations. RESULTS: During a 6-week period, 204 concentrations were measured in 77 patients. The most common dosing regimen was 1 g every 12 hours. Overall, initial trough concentrations were subtherapeutic (<10 mg/L) in 58% of patients and trough concentrations did not become therapeutic at any stage throughout therapy in 25% of patients. The pharmacokinetic modeling software demonstrated little systematic bias (−3.1%), but the precision (median prediction error) was 23% (interquartile range, 11-45%). Predictions were poorer in obese patients (body mass index >35 kg/m2) and in patients with unstable renal function. CONCLUSIONS: A delay in attaining target trough concentrations was observed in a significant proportion of patients. Pharmacokinetic modeling software is a potential tool to improve the timeliness of achieving adequate dosing by allowing concentrations to be determined prior to steady-state. The program was able to predict vancomycin concentrations across a heterogeneous patient population with little systematic bias, but only moderate precision.
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Affiliation(s)
- Maya O Nunn
- Maya O Nunn PharmD, Pharmacist, School of Pharmacy, University of Nottingham, University Park, Nottingham, England
| | - Carmela E Corallo
- Carmela E Corallo BPharm, Clinical Specialist, Department of Pharmacy, Alfred Health, Melbourne, Australia
| | - Cecile Aubron
- Cecile Aubron MD PhD, Intensivist, Department of Epidemiology and Preventive Medicine, Monash University
| | - Susan Poole
- Susan Poole, Grad Dip Epidem Biostat, Research Coordinator, Department of Pharmacy, Alfred Health; Honorary Research Fellow, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University
| | - Michael J Dooley
- Michael J Dooley BPharm Grad Dip Hosp Pharm, Director, Department of Pharmacy, Alfred Health; Professor, Centre for Medicine Use and Safety, Monash University
| | - Allen C Cheng
- Allen C Cheng MBBS FRACP MPH PhD, Associate Professor, Infectious Disease Unit, Alfred Health; Department of Epidemiology and Preventive Medicine, Monash University
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