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Kanazawa N, Shigemi A, Amadatsu N, Arimura K, Shimono S, Oda K, Chuang VTG, Matsumoto K, Kawamura H, Terazono H. A cohort study of the risk factors and the target AUC to avoid vancomycin-associated acute kidney injury in pediatric patients. J Infect Chemother 2024; 30:323-328. [PMID: 37940038 DOI: 10.1016/j.jiac.2023.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES In recent years, Vancomycin (VCM) dosing design using area under the concentration-time curve (AUC) has been recommended as a measure of efficacy and safety, but there are fewer reports on pediatric patients than on adults. In this study, we evaluated the threshold of AUC for AKI occurrence in pediatric patients and investigated the factors that contribute to the occurrence of AKI. METHODS Pediatric patients aged 1-15 years on VCM treatment who underwent TDM at Kagoshima University Hospital from April 2016 to March 2022 were included in the computation of AUC using pediatric population pharmacokinetic parameters. RESULTS The ROC curve showed that the AUC threshold for the risk of developing AKI was 583.0 μg・h/mL, and the AUC-ROC curve was 0.873 (sensitivity 0.930, specificity 0.750). Univariate analysis showed that factors associated with AKI incidence were the duration of VCM administration, ICU admission, and AUCSS. Concomitant medications identified as risk factors for AKI incidence were tazobactam/piperacillin, liposomal amphotericin B, calcineurin inhibitors, contrast agents, and H2-receptor blockers. The multivariate analysis showed that AUC ≧ 583.0 μg・h/mL (odds ratio 20.14, 95% CI 3.52-115.22, p < 0.001) and H2-receptor blockers (odds ratio 8.70, 95% confidence interval = 1.38-54.87, p = 0.02) were independent factors for AKI incidence. CONCLUSIONS We showed that in pediatric patients receiving VCM, the risk of AKI increases as AUC increases. The findings imply that concurrent use of VCM and H2-receptor blockers may increase the risk of AKI.
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Affiliation(s)
- Naoko Kanazawa
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Akari Shigemi
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan; Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Nao Amadatsu
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kotaro Arimura
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Shohei Shimono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1, Honjo, Chuo-ku, Kumamoto-shi, Kumamoto, 860-8556, Japan
| | - Victor Tuan Giam Chuang
- Discipline of Pharmacy, Curtin Medical School, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia
| | - Kazuaki Matsumoto
- Division of Pharmacodynamics, Keio University Faculty of Pharmacy, 1-5-30 Shibakoen, Minato-ku, Tokyo, 105-8512, Japan
| | - Hideki Kawamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan
| | - Hideyuki Terazono
- Department of Pharmacy, Kagoshima University Hospital, 8-35-1, Sakuragaoka, Kagoshima-shi, 890-8520, Japan.
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Shimamoto Y, Fukushima K, Mizuno T, Ichikawa H, Kurosaki K, Maeda S, Okuda M. Model-Informed Vancomycin Dosing Optimization to Address Delayed Renal Maturation in Infants and Young Children with Critical Congenital Heart Disease. Clin Pharmacol Ther 2024; 115:239-247. [PMID: 37994537 DOI: 10.1002/cpt.3095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/29/2023] [Indexed: 11/24/2023]
Abstract
Ensuring safe and effective drug therapy in infants and young children often requires accounting for growth and organ development; however, data on organ function maturation are scarce for special populations, such as infants with congenital diseases. Children with critical congenital heart disease (CCHD) often require multiple staged surgeries depending on their age and disease severity. Vancomycin (VCM) is used to treat postoperative infections; however, the standard pediatric dose (60-80 mg/kg/day) frequently results in overexposure in children with CCHD. In this study, we characterized the maturation of VCM clearance in pediatric patients with CCHD and determined the appropriate dosing regimen using population pharmacokinetic (PK) modeling and simulations. We analyzed 1,254 VCM serum concentrations from 152 postoperative patients (3 days-13 years old) for population PK analysis. The PK model was developed using a two-compartment model with allometrically scaled body weight, estimated glomerular filtration rate (eGFR), and postmenstrual age as covariates. The observed clearance in patients aged ≤ 1 year and 1-2 years was 33% and 40% lower compared with that of non-CCHD patients, respectively, indicating delayed renal maturation in patients with CCHD. Simulation analyses suggested VCM doses of 25 mg/kg/day (age ≤ 3 months, eGFR 40 mL/min/1.73 m2 ) and 35 mg/kg/day (3 months < age ≤ 3 years, eGFR 60 mL/min/1.73 m2 ). In conclusion, this study revealed delayed renal maturation in children with CCHD, could be due to cyanosis and low cardiac output. Model-informed simulations identified the lower VCM doses for children with CCHD compared with standard pediatric guidelines.
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Affiliation(s)
- Yuko Shimamoto
- Department of Pharmacy, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Department of Hospital Pharmacy, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Keizo Fukushima
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shinichiro Maeda
- Center for Advanced Education and Research in Pharmaceutical Sciences Clinical Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Osaka, Japan
| | - Masahiro Okuda
- Department of Hospital Pharmacy, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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3
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Chung E, Seto W. Association between vancomycin therapeutic drug monitoring and clinical outcomes in treating neonatal sepsis. Int J Antimicrob Agents 2023; 62:106958. [PMID: 37633423 DOI: 10.1016/j.ijantimicag.2023.106958] [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: 03/13/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Neonatal sepsis is commonly treated with vancomycin in the neonatal intensive care unit. Therapeutic drug monitoring of vancomycin is routinely used to personalise dosing to optimise effectiveness and avoid toxicity. OBJECTIVES This study aimed to define a target range by evaluating associations between vancomycin trough concentrations or area under the concentration time curve over 24 hours (AUC24h) and clinical outcomes in neonates. METHODS Neonates, who were admitted to the neonatal intensive care unit and received intravenous vancomycin, were included in this retrospective cohort study. For evaluating effectiveness, patients who received vancomycin for < 5 days were excluded. The AUC24h was estimated based on a study-derived population pharmacokinetic model. Primary outcomes were persistent/recurrent infections and mortality within 30 days. Secondary outcomes, including acute kidney injury (AKI), were also assessed. Logistic regression and classification and regression tree analyses were performed. RESULTS A total of 448 patients (123 patients for effectiveness analysis) were included. A vancomycin trough > 10 mg/L was associated with 70% lower odds of persistent/recurrent infections (adjusted OR 0.30, 95% CI 0.09-0.86; P = 0.023). Patients who took more than a day to reach target range had 1.4 times higher odds of persistent/recurrent infections or death (P = 0.04). A vancomycin trough > 15 mg/L was associated with a three times higher risk of AKI (P = 0.003). An AUC24h of 420-650 mg*h/L was also associated with the lowest risk of composite outcomes (adjusted OR 0.29, 95% CI 0.08-0.86; P = 0.025). CONCLUSION A vancomycin trough target range of 10-15 mg/L and achievement of this target within a day of treatment initiation were associated with the most optimal clinical outcomes in treating neonatal sepsis.
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Affiliation(s)
- Erin Chung
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto Ontario, Canada
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4
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Hughes JH, Tong DMH, Faldasz JD, Frymoyer A, Keizer RJ. Evaluation of Neonatal and Paediatric Vancomycin Pharmacokinetic Models and the Impact of Maturation and Serum Creatinine Covariates in a Large Multicentre Data Set. Clin Pharmacokinet 2023; 62:67-76. [PMID: 36404388 PMCID: PMC9898357 DOI: 10.1007/s40262-022-01185-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Infants and neonates present a clinical challenge for dosing drugs with high interindividual variability due to these patients' rapid growth and the interplay between maturation and organ function. Model-informed precision dosing (MIPD), which can account for interindividual variability via patient characteristics and Bayesian forecasting, promises to improve individualized dosing strategies in this complex population. Here, we assess the predictive performance of published population pharmacokinetic models describing vancomycin in neonates and infants, and analyze the robustness of these models in the face of clinical uncertainty surrounding covariate values. METHODS The predictive precision and bias of nine pharmacokinetic models were compared in a large multi-site data set (N = 2061 patients, 5794 drug levels, 28 institutions) of patients aged 0-365 days. The robustness of model predictions to errors in serum creatinine measurements and gestational age was assessed by using recorded values or by replacing covariate values with 0.3, 0.5 or 0.8 mg/dL or with 40 weeks, respectively. RESULTS Of the nine models, two models (Dao and Jacqz-Aigrain) resulted in predicted concentrations within 2.5 mg/L or 15% of the measured values for at least 60% of population predictions. Within individual models, predictive performance often 2 differed in neonates (0-4 weeks) versus older infants (15-52 weeks). For preterm neonates, imputing gestational age as 40 weeks reduced the accuracy of model predictions. Measured values of serum creatinine improved model predictions compared to using imputed values even in neonates ≤1 week of age. CONCLUSIONS Several available pharmacokinetic models are suitable for MIPD in infants and neonates. Availability and accuracy of model covariates for patients will be important for guiding dose decision-making.
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Affiliation(s)
- Jasmine H Hughes
- InsightRX, 548 Market St. #88083, San Francisco, CA, 94104, USA.
| | | | | | - Adam Frymoyer
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Ron J Keizer
- InsightRX, 548 Market St. #88083, San Francisco, CA, 94104, USA
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5
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Pilot Pharmacokinetic Study in Healthy Adults Using Intravascular Microdialysis Catheters Modified for Use in Paediatric Patients to Assess Vancomycin Blood Levels. Clin Pharmacokinet 2023; 62:77-87. [PMID: 36471223 PMCID: PMC9898326 DOI: 10.1007/s40262-022-01190-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE Exhaustive pharmacokinetic (PK) studies in paediatric patients are unavailable for most antibiotics and feasibility of PK studies is limited by challenges, such as low blood volume and venipuncture-related pain. Microdialysis (MD) represents a promising method to overcome these obstacles. The aim of this proof-of-concept study was to develop and validate modified MD catheters that can be used to obtain concentration-time profiles of antibiotics in paediatric patients. METHODS Following extensive in vitro MD experiments, a prospective open-labelled study in ten healthy adult volunteers (HVs) was conducted. Subjects received a single intravenous dose of 1000 mg vancomycin, then plasma and intravascular microdialysate were sampled over 24 h. In vivo MD probe calibration was conducted using the retrodialysis technique. Plasma protein binding was measured using ultrafiltration. Confirmation of the measurements was performed using a Bland-Altman plot, relevant PK parameters were calculated, and a pharmacometric model was established. RESULTS No safety issues were encountered. The concentration-time curves of microdialysate and plasma measurements showed good alignment. The Bland-Altman plot yielded a mean bias of 0.19 mg/L and 95% limits of agreement of - 9.34 to 9.71 mg/L. A two-compartment model best described plasma PK, model-based estimates for recovery of the MD probes being in high agreement with the observed values. Quantified estimates of fraction unbound were comparable between plasma and microdialysate (p = 0.56). CONCLUSIONS An innovative MD catheter that can be inserted into small intravenous lines was successfully developed and applied in HV. This proof-of-concept study is encouraging and opens the way to further experiments leading towards future use of MD in paediatric patients.
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Aljutayli A, Thirion DJ, Nekka F. Critical assessment of the revised guidelines for vancomycin therapeutic drug monitoring. Biomed Pharmacother 2022; 155:113777. [DOI: 10.1016/j.biopha.2022.113777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/02/2022] Open
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Ghasemiyeh P, Vazin A, Zand F, Haem E, Karimzadeh I, Azadi A, Masjedi M, Sabetian G, Nikandish R, Mohammadi-Samani S. Pharmacokinetic assessment of vancomycin in critically ill patients and nephrotoxicity prediction using individualized pharmacokinetic parameters. Front Pharmacol 2022; 13:912202. [PMID: 36091788 PMCID: PMC9449142 DOI: 10.3389/fphar.2022.912202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/15/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction: Therapeutic drug monitoring (TDM) and pharmacokinetic assessments of vancomycin would be essential to avoid vancomycin-associated nephrotoxicity and obtain optimal therapeutic and clinical responses. Different pharmacokinetic parameters, including trough concentration and area under the curve (AUC), have been proposed to assess the safety and efficacy of vancomycin administration. Methods: Critically ill patients receiving vancomycin at Nemazee Hospital were included in this prospective study. Four blood samples at various time intervals were taken from each participated patient. Vancomycin was extracted from plasma samples and analyzed using a validated HPLC method. Results: Fifty-three critically ill patients with a total of 212 blood samples from June 2019 to June 2021 were included in this study. There was a significant correlation between baseline GFR, baseline serum creatinine, trough and peak concentrations, AUCτ, AUC24h, Cl, and Vd values with vancomycin-induced AKI. Based on trough concentration values, 66% of patients were under-dosed (trough concentration <15 μg/ml) and 18.9% were over-dosed (trough concentration ≥20 μg/ml). Also, based on AUC24h values, about 52.2% were under-dosed (AUC24h < 400 μg h/ml), and 21.7% were over-dosed (AUC24h > 600 μg h/ml) that emphasizes on the superiority of AUC-based monitoring approach for TDM purposes to avoid nephrotoxicity occurrence. Conclusion: The AUC-based monitoring approach would be superior in terms of nephrotoxicity prediction. Also, to avoid vancomycin-induced AKI, trough concentration and AUCτ values should be maintained below the cut-off points.
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Affiliation(s)
- Parisa Ghasemiyeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Afsaneh Vazin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- *Correspondence: Soliman Mohammadi-Samani, ; Afsaneh Vazin,
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Elham Haem
- Department of Biostatistics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Iman Karimzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Azadi
- Department of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mansoor Masjedi
- Department of Anesthesiology, Faculty of Medicine, Shiraz University of Medical Science, Shiraz, Iran
| | - Golnar Sabetian
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Nikandish
- Anesthesiology and Critical Care Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soliman Mohammadi-Samani
- Department of Pharmaceutics, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
- *Correspondence: Soliman Mohammadi-Samani, ; Afsaneh Vazin,
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Chuphan C, Sukarnjanaset W, Puthanakit T, Wattanavijitkul T. Population Pharmacokinetics and Pharmacodynamics of Vancomycin in Pediatric Patients With Various Degrees of Renal Function. J Pediatr Pharmacol Ther 2022; 27:419-427. [DOI: 10.5863/1551-6776-27.5.419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE
Although vancomycin dosage recommendations in the pediatric setting for methicillin-resistant Staphylococcus aureus (MRSA) infection indicate that ≥60 mg/kg/day is correlated to a desired area under the vancomycin concentration time curve from 0 to 24 hours to minimum inhibitory concentration ratio (AUC0–24 hr/MIC) ≥400, for some patients this dosage is inadequate or relates to toxicity. This study purposed to explore vancomycin dosing for pediatrics with various degrees of renal function.
METHODS
Routine monitoring data were retrospectively collected from patients, aged 1 month to 18 years. Population pharmacokinetic analysis was performed by using non-linear mixed-effect model with NONMEM software, and Monte Carlo simulation was conducted by using Crystal Ball software.
RESULTS
Two hundred twelve patients with 348 vancomycin serum concentrations were included. Median age was 3.5 years (IQR, 0.9–10.9), median weight was 14.0 kg (IQR, 7.2–30.4), with baseline estimated glomerular filtration rate (eGFR) ranging from 15.5 to 359.3 mL/min/1.73 m2. A 1-compartment model with first-order elimination sufficiently described vancomycin PK. The dosing targeting AUC0–24hr/MIC ≥400 and AUC0–24hr <800 mg•h/L for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2 was 12.5, 25, 40, 60, and 70 mg/kg/day, respectively. All vancomycin dosing obtained >85% of the cumulative fraction of response across the MIC distribution of MRSA.
CONCLUSIONS
Vancomycin dosing of 12.5, 25, 40, 60, and 70 mg/kg/day is suggested for pediatric patients with eGFRs of 15 to 29, 30 to 59, 60 to 89, 90 to 129, and 130 to 160 mL/min/1.73 m2, respectively.
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Affiliation(s)
- Chanika Chuphan
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | | | - Thanyawee Puthanakit
- Department of Pediatrics (TP), Center of Excellence for Pediatric Infectious Diseases and Vaccines, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thitima Wattanavijitkul
- Department of Pharmacy Practice (CC, TW), Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
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Han J, Sauberan J, Tran MT, Adler-Shohet FC, Michalik DE, Tien TH, Tran L, DO DH, Bradley JS, Le J. Implementation of Vancomycin Therapeutic Monitoring Guidelines: Focus on Bayesian Estimation Tools in Neonatal and Pediatric Patients. Ther Drug Monit 2022; 44:241-252. [PMID: 34145165 DOI: 10.1097/ftd.0000000000000910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The 2020 consensus guidelines for vancomycin therapeutic monitoring recommend using Bayesian estimation targeting the ratio of the area under the curve over 24 hours to minimum inhibitory concentration as an optimal approach to individualize therapy in pediatric patients. To support institutional guideline implementation in children, the objective of this study was to comprehensively assess and compare published population-based pharmacokinetic (PK) vancomycin models and available Bayesian estimation tools, specific to neonatal and pediatric patients. METHODS PubMed and Embase databases were searched from January 1994 to December 2020 for studies in which a vancomycin population PK model was developed to determine clearance and volume of distribution in neonatal and pediatric populations. Available Bayesian software programs were identified and assessed from published articles, software program websites, and direct communication with the software company. In the present review, 14 neonatal and 20 pediatric models were included. Six programs (Adult and Pediatric Kinetics, BestDose, DoseMeRx, InsightRx, MwPharm++, and PrecisePK) were evaluated. RESULTS Among neonatal models, Frymoyer et al and Capparelli et al used the largest PK samples to generate their models, which were externally validated. Among the pediatric models, Le et al used the largest sample size, with multiple external validations. Of the Bayesian programs, DoseMeRx, InsightRx, and PrecisePK used clinically validated neonatal and pediatric models. CONCLUSIONS To optimize vancomycin use in neonatal and pediatric patients, clinicians should focus on selecting a model that best fits their patient population and use Bayesian estimation tools for therapeutic area under the -curve-targeted dosing and monitoring.
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Affiliation(s)
- Jihye Han
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | - Jason Sauberan
- Neonatal Research Institute, SHARP Mary Birch Hospital for Women and Newborns, San Diego
| | | | | | - David E Michalik
- MemorialCare Miller Children's and Women's Hospital Long Beach, Long Beach, California
| | | | - Lan Tran
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
| | | | - John S Bradley
- Division of Infectious Diseases, University of California at San Diego, Louisiana Jolla; and
- Rady Children's Hospital-San Diego, San Diego, California
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, Louisiana Jolla
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10
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Gwee A, Duffull SB, Daley AJ, Lim M, Germano S, Bilal H, Hall S, Curtis N, Zhu X. Identifying a therapeutic target for vancomycin against staphylococci in young infants. J Antimicrob Chemother 2022; 77:704-710. [PMID: 35037934 DOI: 10.1093/jac/dkab469] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 11/17/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To determine the therapeutic target of vancomycin in young infants with staphylococcal infections. METHODS Retrospective data were collected for infants aged 0 to 90 days with CoNS or MRSA bacteraemia over a 4 year period at the Royal Children's Hospital Melbourne, Australia. Vancomycin broth microdilution MICs were determined. A published pharmacokinetic model was externally validated using the study dataset and a time-to-event (TTE) pharmacodynamic model developed to link the AUC of vancomycin with the event being the first negative blood culture. Simulations were performed to determine the trough vancomycin concentration that correlates with a 90% PTA of the target AUC24. RESULTS Thirty infants, 28 with CoNS and 2 with MRSA bacteraemia, who had 165 vancomycin concentrations determined were included. The vancomycin broth microdilution MIC was determined for 24 CoNS and 1 MRSA isolate, both with a median MIC of 1 mg/L (CoNS range = 0.5-4.0). An AUC0-24 target of ≥300 mg/L·h or AUC24-48 of ≥424 mg/L·h. increased the chance of bacteriological cure by 7.8- and 7.3-fold, respectively. However, AUC0-24 performed best in the pharmacokinetic-pharmacodynamic model. This correlates with 24 to 48 h trough concentrations of >15-18 mg/L and >10-15 mg/L for 6- and 12-hourly dosing, respectively, and can be used to guide vancomycin therapy in this population. CONCLUSIONS An AUC0-24 ≥300 mg/L·h or AUC24-48 ≥424 mg/L·h was associated with an increase in bacteriological cure in young infants with staphylococcal bloodstream infections.
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Affiliation(s)
- Amanda Gwee
- Department of Infectious Diseases and Clinical Pharmacology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Infectious Diseases & Microbiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen B Duffull
- Otago Pharmacometrics Group, School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Andrew J Daley
- Department of Infectious Diseases and Clinical Pharmacology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Infectious Diseases & Microbiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Michelle Lim
- Department of Laboratory Services, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Susie Germano
- Infectious Diseases & Microbiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Hajira Bilal
- Department of Infectious Diseases and Clinical Pharmacology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Infectious Diseases & Microbiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Samantha Hall
- Department of Infectious Diseases and Clinical Pharmacology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Infectious Diseases & Microbiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Nigel Curtis
- Department of Infectious Diseases and Clinical Pharmacology, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
- Infectious Diseases & Microbiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - Xiao Zhu
- Department of Clinical Pharmacy and Pharmacy Administration, School of Pharmacy, Fudan University, Shanghai, China
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11
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Akunne OO, Mugabo P, Argent AC. Pharmacokinetics of Vancomycin in Critically Ill Children: A Systematic Review. Eur J Drug Metab Pharmacokinet 2021; 47:31-48. [PMID: 34750740 PMCID: PMC8574943 DOI: 10.1007/s13318-021-00730-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/26/2022]
Abstract
Background and Objective Vancomycin is often used in the ICU for the treatment of Gram-positive bacterial infection. In critically ill children, there are pathophysiologic changes that affect the pharmacokinetics of vancomycin. A systematic review of vancomycin pharmacokinetics and pharmacodynamics in critically ill children was performed. Methods Pharmacokinetic studies of vancomycin in critically ill children published up to May 2021 were included in the review provided they included children aged > 1 month. Studies including neonates were excluded. A search was performed using the PubMed, Scopus, and Google Scholar databases. The Risk of Bias Assessment Tool for Systematic Reviews (ROBIS) was used to check for quality and reduce bias. Data on study characteristics, patient demographics, clinical parameters, pharmacokinetic parameters, outcomes, and study limitations were collected. Results Thirteen studies were included in this review. A wide variety of dosing and sampling strategies were used in the studies. Methods for estimating vancomycin pharmacokinetics, especially the area under the curve over 24 h, varied. Vancomycin doses of 20–60 mg/kg were given daily. This resulted in high variability in pharmacokinetic parameters. Vancomycin trough level was less than 15 μg/mL in most of the studies. Vancomycin clearance ranged from 0.05 to 0.38 L/h/kg. Volume of distribution ranged from 0.1 to 1.16 L/kg. Half-life was between 2.4 and 23.6 h. Patients in the study receiving continuous vancomycin infusion had AUC24 < 400 µg·h/mL. Conclusion There is large variability in the pharmacokinetics of vancomycin among critically ill patients. Studies to assess the factors responsible for this variability in vancomycin pharmacokinetics are needed.
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Affiliation(s)
- Onyinye Onyeka Akunne
- Discipline of Pharmacology, School of Pharmacy, University of the Western Cape, Bellville, Cape Town, 7535 South Africa
| | - Pierre Mugabo
- Discipline of Pharmacology, School of Pharmacy, University of the Western Cape, Bellville, Cape Town, 7535 South Africa
| | - Andrew C Argent
- Paediatrics and Child Health, University of Cape Town, Rondebosch, Cape Town, 7700 South Africa
- Paediatric Intensive Care Unit, Red Cross War Memorial Children Hospital, Rondebosch, Cape Town, 7700 South Africa
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12
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Aljutayli A, El-Haffaf I, Marsot A, Nekka F. An Update on Population Pharmacokinetic Analyses of Vancomycin, Part II: In Pediatric Patients. Clin Pharmacokinet 2021; 61:47-70. [PMID: 34671937 DOI: 10.1007/s40262-021-01050-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 10/20/2022]
Abstract
Vancomycin is widely used in pediatric patients, however, large inter- and intraindividual variability are observed in vancomycin pharmacokinetics, affecting proper therapeutic monitoring. This review aimed at providing a comprehensive synthesis of the population pharmacokinetic models of vancomycin in pediatric patients and identifying potential factors responsible for the variability observed in various subpopulations. We conducted a literature search of the PubMed and EMBASE databases to obtain population pharmacokinetic studies for vancomycin published between January 2011 and January 2020, which resulted in a total of 33 studies. Vancomycin pharmacokinetics were generally characterized using a one-compartment model (n = 27), while a two-compartment model was used in six studies. The median (interquartile range) of the typical vancomycin clearance (CL) and the total volume of distribution adjusted to the median or mean body weight of the respective study was 0.103 L/h/kg (0.071-0.125) and 0.64 L/kg (0.59-1.03), respectively. Median weight-adjusted CL between different child age groups, such as infants and adolescents, did not appear to vary significantly, although the sample size for many age groups was very small. Examples of the conditions with relatively abnormal vancomycin pharmacokinetic values include renal insufficiency, sepsis, hematological and solid malignancy, and hypothermia treatment. Factors influencing pediatric vancomycin pharmacokinetics after adjusting for size and maturation include various renal function descriptors and some case-specific variables such as dialysate flow rate, ultrafiltrate output, and hypothermia. This review was able to document possible variables explaining the high variability observed in certain subpopulations and contrast vancomycin pharmacokinetics in different pediatric subpopulations.
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Affiliation(s)
- Abdullah Aljutayli
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de Pharmacométrie, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Ibrahim El-Haffaf
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada
| | - Amélie Marsot
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada. .,Laboratoire de suivi thérapeutique pharmacologique et pharmacocinétique, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada. .,Centre de recherche, CHU Sainte-Justine, 175 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
| | - Fahima Nekka
- Faculty of Pharmacy, Université de Montréal, 2940 chemin de polytechnique, Montreal, H3T 1J4, Canada.,Laboratoire de Pharmacométrie, Faculté de Pharmacie, Université de Montréal, 2940 chemin de polytechnique, Montreal, QC, H3T 1J4, Canada.,Centre de recherches mathématiques, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montreal, QC, Canada, H3T 1J4
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13
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Shimamoto Y, Verstegen RHJ, Mizuno T, Schechter T, Allen U, Ito S. Population pharmacokinetics of vancomycin in paediatric patients with febrile neutropenia and augmented renal clearance: development of new dosing recommendations. J Antimicrob Chemother 2021; 76:2932-2940. [PMID: 34480578 DOI: 10.1093/jac/dkab302] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 07/23/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate the influence of augmented renal clearance (ARC) on vancomycin clearance and provide dosage recommendations for paediatric patients with febrile neutropenia following HSCT. METHODS A population pharmacokinetic analysis was performed based on a two-compartment model structure using a non-linear mixed-effect modelling approach. Monte Carlo simulations were conducted as a target attainment analysis of AUC between 400 mg·h/L and 650 mg·h/L for MRSA at an MIC of 1 mg/L. RESULTS A total of 165 paediatric patients and 276 vancomycin serum concentrations were analysed in this study. Age, body weight, estimated glomerular filtration rate (eGFR) and fever (≥38.0°C) were identified as factors that significantly influenced vancomycin clearance. The median eGFR of the population was 143 mL/min/1.73 m2 and 34% of patients showed an eGFR ≥160 mL/min/1.73 m2, which may be classified as ARC. Our simulations showed that current dosing recommendations result in poor target attainment. In particular, children aged 6 months old to 6 years old with ARC require an initial vancomycin dose up to 35%-65% higher than the current dosing guidelines. CONCLUSIONS ARC is frequently observed in paediatric patients with post-HSCT febrile neutropenia, resulting in a significant increase in vancomycin clearance. We propose a vancomycin dosing strategy for children with febrile neutropenia following HSCT based on eGFR, age, weight and body temperature.
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Affiliation(s)
- Yuko Shimamoto
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ruud H J Verstegen
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Tal Schechter
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Hematology/Oncology/BMT, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Upton Allen
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shinya Ito
- Division of Clinical Pharmacology and Toxicology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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14
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Li H, Yang Q, Gui M, Ding L, Yang L, Sun H, Li Z. Changes of renal transporters in the kinetic process of VCM-induced nephrotoxicity in mice. Toxicol Res (Camb) 2021; 10:687-695. [PMID: 34484661 DOI: 10.1093/toxres/tfab048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 03/31/2021] [Accepted: 05/10/2021] [Indexed: 11/14/2022] Open
Abstract
Renal transporters involved in tubular excretion pathway are considered to be the key concern in drug evaluations in nephrotoxicity. However, the relationship between the alternation of renal transporters and the kinetic process of vancomycin (VCM)-induced nephrotoxicity has not been fully elucidated. The present study investigated the alteration of renal transporters expression in the kinetic process of VCM-induced nephrotoxicity in mice. C57BL/6 mice were administrated with normal saline or VCM for 7 days. Biochemical and pathological analyses were conducted to investigate the nephrotoxicity induced by VCM administration. Renal oxidative status, plasma, and kidney content of VCM were monitored. Quantitative real-time polymerase chain reaction and immunohistochemistry analyses were performed to analyze the expression of renal transporters. Finally, our data showed that the exposure of VCM (400 mg/kg) caused a slight nephrotoxicity in mice, whereas exposure of VCM (600 mg/kg) resulted in the severe nephrotoxicity in mice as evidenced by biochemical parameters and renal morphological changes. In addition, the accumulation of VCM in kidney is higher than plasma. Interestingly, VCM (600 mg/kg, body weight) resulted in the induction of Oct2-Mate1 and Oat1/3-Mrp2/Mrp4/Bcrp pathways. However, VCM (400 mg/kg, body weight) caused the induction of Oct2-Mate1/Mate2 and Oat1/3-Mrp4/Bcrp pathways. The changes of renal transporters in association with the kinetic process of VCM-induced nephrotoxicity may exert important practical implications for its optimal use in clinic.
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Affiliation(s)
- Hongjing Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Qiaoling Yang
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Mingzhu Gui
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Lili Ding
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Li Yang
- Institute of Chinese Materia Medica, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Huajun Sun
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
| | - Zhiling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai 200062, China
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15
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Population Pharmacokinetic Models of Vancomycin in Paediatric Patients: A Systematic Review. Clin Pharmacokinet 2021; 60:985-1001. [PMID: 34002357 DOI: 10.1007/s40262-021-01027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Vancomycin is commonly used to treat gram-positive bacterial infections in the paediatric population, but dosing can be challenging. Population pharmacokinetic (popPK) modelling can improve individualization of dosing regimens. The primary objective of this study was to describe popPK models of vancomycin and factors that influence pharmacokinetic (PK) variability in paediatric patients. METHODS Systematic searches were conducted in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, International Pharmaceutical Abstracts and the grey literature without language or publication status restrictions from inception to 17 August 2020. Observational studies that described the development of popPK models of vancomycin in paediatric patients (< 18 years of age) were included. Risk of bias was assessed using the National Heart, Lung and Blood Institute Study Quality Assessment Tool for Case Series Studies. RESULTS Sixty-four observational studies (1 randomized controlled trial, 13 prospective studies and 50 retrospective studies of 9019 patients with at least 25,769 serum vancomycin concentrations) were included. The mean age was 2.5 years (range 1 day-18 years), serum creatinine was 47.1 ± 33.6 µmol/L, and estimated creatinine clearance was 97.4 ± 76 mL/min/1.73m2. Most studies found that vancomycin PK was best described by a one-compartment model (71.9%). There was a wide range of clearance and volume of distribution (Vd) values (range 0.014-0.27 L/kg/h and 0.43-1.46 L/kg, respectively) with interindividual variability as high as 49.7% for clearance and 136% for Vd, proportional residual variability up to 37.5% and additive residual variability up to 17.5 mg/L. The most significant covariates for clearance were weight, age, and serum creatinine or creatinine clearance, and weight for Vd. Variable dosing recommendations were suggested. CONCLUSION Numerous popPK models of vancomycin were derived, however external validation of suggested dosing regimens and analyses in subgroup paediatric populations such as dialysis patients are still needed before a popPK model with best predictive performance can be applied for dosing recommendations. Significant intraindividual and interindividual PK variability was present, which demonstrated the need for ongoing therapeutic drug monitoring and derivation of PK models for vancomycin for certain subgroup populations, such as dialysis patients.
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16
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van Donge T, Smits A, van den Anker J, Allegaert K. Amikacin or Vancomycin Exposure Alters the Postnatal Serum Creatinine Dynamics in Extreme Low Birth Weight Neonates. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020662. [PMID: 33466764 PMCID: PMC7830583 DOI: 10.3390/ijerph18020662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 01/03/2023]
Abstract
Background: Disentangling renal adverse drug reactions from confounders remains a major challenge to assess causality and severity in neonates, with additional limitations related to the available tools (modified Kidney Disease Improving Global Outcome, or Division of Microbiology and Infectious Diseases pediatric toxicity table). Vancomycin and amikacin are nephrotoxic while still often prescribed in neonates. We selected these compounds to assess their impact on creatinine dynamics as a sensitive tool to detect a renal impairment signal. Methods: A recently developed dynamical model that characterized serum creatinine concentrations of 217 extremely low birth weight (<1000 g, ELBW) neonates (4036 observations) was enhanced with data on vancomycin and/or amikacin exposure to identify a potential effect of antibiotic exposure by nonlinear mixed-effects modelling. Results: Seventy-seven percent of ELBW patients were exposed to either vancomycin or amikacin. Antibiotic exposure resulted in a modest increase in serum creatinine and a transient decrease in creatinine clearance. The serum creatinine increase was dependent on gestational age, illustrated by a decrease with 56% in difference in serum creatinine between a 24 or 32-week old neonate, when exposed in the 3rd week after birth. Conclusions: A previously described model was used to explore and quantify the impact of amikacin or vancomycin exposure on creatinine dynamics. Such tools serve to explore minor changes, or compare minor differences between treatment modalities.
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Affiliation(s)
- Tamara van Donge
- Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4001 Basel, Switzerland; (T.v.D.); (J.v.d.A.)
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Neonatal Intensive Care Unit, University Hospitals Leuven, 3000 Leuven, Belgium
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4001 Basel, Switzerland; (T.v.D.); (J.v.d.A.)
- Division of Clinical Pharmacology, Children’s National Health Hospital, Washington, DC 20010, USA
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, 3015 Rotterdam, The Netherlands
- Correspondence: ; Tel.: +32-016-342020
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17
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Al-Khouja A, Park K, Anderson DJ, Young C, Wang J, Huang SM, Khurana M, Burckart GJ. Dosing Recommendations for Pediatric Patients With Renal Impairment. J Clin Pharmacol 2020; 60:1551-1560. [PMID: 32542790 PMCID: PMC8670561 DOI: 10.1002/jcph.1676] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/22/2020] [Indexed: 01/10/2023]
Abstract
A treatment gap exists for pediatric patients with renal impairment. Alterations in renal clearance and metabolism of drugs render standard dosage regimens inappropriate and may lead to drug toxicity, but these studies are not routinely conducted during drug development. The objective of this study was to examine the clinical evidence behind current renal impairment dosage recommendations for pediatric patients in a standard pediatric dosing handbook. The sources of recommendations and comparisons included the pediatric dosing handbook (Lexicomp), the U.S. Food and Drug Administration-approved manufacturer's labels, and published studies in the literature. One hundred twenty-six drugs in Lexicomp had pediatric renal dosing recommendations. Only 14% (18 of 126) of Lexicomp pediatric renal dosing recommendations referenced a pediatric clinical study, and 15% of manufacturer's labels (19 of 126) described specific dosing regimens for renally impaired pediatric patients. Forty-two products had published information on pediatric renal dosing, but 19 (45%) were case studies. When pediatric clinical studies were not referenced in Lexicomp, the renal dosing recommendations followed the adult and pediatric dosing recommendations on the manufacturer's label. Clinical evidence in pediatric patients does not exist for most renal dosing recommendations in a widely used pediatric dosing handbook, and the adult renal dosing recommendations from the manufacturer's label are currently the primary source of pediatric renal dosing information.
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Affiliation(s)
- Amer Al-Khouja
- Division of Clinical Pharmacology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyunghun Park
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Daijha J.C. Anderson
- Eshelman School of Pharmacy,University of North Carolina,Chapel Hill, North Carolina, USA
| | - Caitlyn Young
- University of Southern California, Los Angeles, California, USA
| | - Jian Wang
- Office of Drug Evaluation IV, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Shiew Mei Huang
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mona Khurana
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Gilbert J. Burckart
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Hughes JH, Tong DMH, Lucas SS, Faldasz JD, Goswami S, Keizer RJ. Continuous Learning in Model-Informed Precision Dosing: A Case Study in Pediatric Dosing of Vancomycin. Clin Pharmacol Ther 2020; 109:233-242. [PMID: 33068298 PMCID: PMC7839485 DOI: 10.1002/cpt.2088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/05/2020] [Indexed: 12/21/2022]
Abstract
Model‐informed precision dosing (MIPD) leverages pharmacokinetic (PK) models to tailor dosing to an individual patient’s needs, improving attainment of therapeutic drug exposure targets and thus potentially improving drug efficacy or reducing adverse events. However, selection of an appropriate model for supporting clinical decision making is not trivial. Error or bias in dose selection may arise if the selected model was developed in a population not fully representative of the intended MIPD population. One previously proposed approach is continuous learning, in which an initial model is used in MIPD and then updated as additional data becomes available. In this case study of pediatric vancomycin MIPD, the potential benefits of the continuous learning approach are investigated. Five previously published models were evaluated and found to perform adequately in a data set of 273 pediatric patients in the intensive care unit. Additionally, two predefined simple PK models were fitted on separate populations of 50–350 patients in an approach mimicking clinical implementation of automated continuous learning. With these continuous learning models, prediction error using population PK parameters could be reduced by 2–13% compared with previously published models. Sample sizes of at least 200 patients were found suitable for capturing the interindividual variability in vancomycin at this institution, with limited benefits of larger data sets. Although comprised mostly of trough samples, these sparsely sampled routine clinical data allowed for reasonable estimation of simulated area under the curve (AUC). Together, these findings lay the foundations for a continuous learning MIPD approach.
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Affiliation(s)
| | | | - Sarah Scarpace Lucas
- Department of Clinical Pharmacy, UCSF Medical Center, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Ron J Keizer
- Department of Clinical Pharmacy, UCSF Medical Center, University of California, San Francisco, San Francisco, California, USA
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Early Bayesian Dose Adjustment of Vancomycin Continuous Infusion in Children: a Randomized Controlled Trial. Antimicrob Agents Chemother 2019:AAC.01102-19. [PMID: 31591117 DOI: 10.1128/aac.01102-19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Methicillin-resistant staphylococcal infections are a global burden. Area under the serum concentration-time curve to minimum inhibitory concentration (AUC/MIC) ratio is the pharmacokinetic (PK) parameter that best predicts vancomycin efficacy. Its therapeutic range is narrow, difficult to achieve because of a wide intersubject variability, especially in children, and is not routinely targeted since the AUC is rarely available. We investigated if an early Bayesian dose adjustment would increase the rate of vancomycin target attainment, in the first 24 hours of treatment (H24), in children.We conducted a single-centre randomized controlled trial in 4 pediatric departments of Necker-Enfants Malades hospital (Paris, France). Patients aged 3 months to 17 years for whom intravenous vancomycin was started were eligible and randomized in a 1:1 ratio: routine care were compared with an early vancomycin therapeutic drug monitoring (3h after treatment initiation) followed by an early Bayesian dose adjustment using a previously published population-based PK model that included age, bodyweight and serum creatinine as covariates. The primary outcome was the proportion of patients of each group achieving vancomycin therapeutic range at H24, defined by AUC0-24/MIC≥400 and AUC0-24 ≤800mg-h/L.Ninety-nine patients were enrolled: 49 were randomized to the Bayesian group and 50 to the control group. Modified intention-to-treat analysis included 82 patients: 85% of Bayesian group patients achieved H24 vancomycin target versus 57% of control group patients (p=0.007) with no difference regarding iatrogenic events. Early Bayesian dose adjustment increased the proportion of children achieving vancomycin target at H24, which may improve clinical outcomes of methicillin-resistant staphylococcal infections.
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