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Robosa RS, Lau C, Stojanova J, Chin CW, Marriott DJE. Ceftazidime Plasma Concentrations and Neurotoxicity: The Importance of Therapeutic Drug Monitoring in Patients Undergoing Different Modalities of Renal Replacement Therapy. A Grand Round. Ther Drug Monit 2023; 45:711-713. [PMID: 37448154 DOI: 10.1097/ftd.0000000000001124] [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: 01/25/2023] [Accepted: 05/21/2023] [Indexed: 07/15/2023]
Abstract
ABSTRACT Ceftazidime-avibactam (CTZ-AVM) is a novel cephalosporin/beta-lactamase inhibitor with broad-spectrum activity against multidrug-resistant Pseudomonas aeruginosa . Ceftazidime-induced neurotoxicity is a well-described adverse effect, particularly in patients with renal insufficiency. However, appropriate dosing of ceftazidime-avibactam in patients undergoing renal replacement therapy (RRT) is sparsely investigated, and therapeutic drug monitoring to guide dosing remains lacking. Furthermore, when dose adjustment for impaired renal function is based on CTZ-AVM product information, inferior cure rates have been obtained compared with those with the standard therapy for intra-abdominal infections. Maintaining an effective dose while avoiding toxicity in these patients is challenging. Here, the authors describe the case of a critically ill patient, undergoing 2 modalities of RRT, who developed ceftazidime-induced neurotoxicity as confirmed using ceftazidime therapeutic drug monitoring. This case illustrates a therapeutic drug monitoring-based approach for guiding ceftazidime-avibactam dosing in this context and in diagnosing the cause of neurological symptoms and signs.
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Affiliation(s)
- Roselle S Robosa
- Department of Microbiology and Infectious Diseases, St Vincent's Hospital
| | - Cindy Lau
- Pharmacy Department, St Vincent's Hospital
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney
| | - Jana Stojanova
- Department of Clinical Pharmacology and Toxicology, St. Vincent's Hospital
| | | | - Deborah J E Marriott
- Department of Microbiology and Infectious Diseases, St Vincent's Hospital
- School of Medicine, University of New South Wales, Sydney, Australia
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2
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Hunt JP, McKnite AM, Green DJ, Whelan AJ, Imburgia CE, Watt KM. Interaction of ceftazidime and clindamycin with extracorporeal life support. J Infect Chemother 2023; 29:1119-1125. [PMID: 37572979 PMCID: PMC11160944 DOI: 10.1016/j.jiac.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Ceftazidime and clindamycin are commonly prescribed to critically ill patients who require extracorporeal life support such as ECMO and CRRT. The effect of ECMO and CRRT on the disposition of ceftazidime and clindamycin is currently unknown. METHODS Ceftazidime and clindamycin extraction were studied with ex vivo ECMO and CRRT circuits primed with human blood. The percent recovery of these drugs over time was calculated to determine the degree of interaction between these drugs and circuit components. RESULTS Neither ceftazidime nor clindamycin exhibited measurable interactions with the ECMO circuit. In contrast, CRRT cleared 100% of ceftazidime from the experimental circuit within the first 2 h. Clearance of clindamycin from the CRRT circuit was slower, with about 20% removed after 6 h. CONCLUSION Clindamycin and ceftazidime dosing adjustments are likely required in patients who are supported with CRRT, and future studies to quantify these adjustments should consider the pathophysiology of the patient in combination with the clearance due to CRRT. Dosing adjustments to account for adsorption to ECMO circuit components are likely unnecessary and should focus instead on the pathophysiology of the patient and changes in volume of distribution. These results will help improve the safety and efficacy of ceftazidime and clindamycin in patients requiring ECMO and CRRT.
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Affiliation(s)
- J. Porter Hunt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Autumn M. McKnite
- Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah, USA
| | - Danielle J. Green
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Aviva J. Whelan
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Carina E. Imburgia
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Kevin M. Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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3
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Acquier M, De Précigout V, Delmas Y, Dubois V, M'Zali F, Zabala A, De-La-Faille R, Rubin S, Cazanave C, Puges M, Combe C, Kaminski H. [Diagnosis and treatment of catheter-related bloodstream infection in hemodialysis: 10 years later]. Nephrol Ther 2022; 18:80-88. [PMID: 35033479 DOI: 10.1016/j.nephro.2021.08.010] [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: 03/27/2021] [Revised: 08/10/2021] [Accepted: 08/19/2021] [Indexed: 10/19/2022]
Abstract
Patients in hemodialysis on central venous catheter as vascular access are at risk of infections. Catheter-related bloodstream infection is one of the most serious catheter-complications in hemodialysis patients. Its clinical and microbiological diagnosis is challenging. The implementation of empiric antibiotic therapy is based on old recommendations proposing the combination of a molecule targeting methicillin-resistant Staphylococcus aureus and a betalactamin active on P. aeruginosa, and also adapting this probabilistic treatment by carrying out a microbiological register on a local scale, which is rarely done. In our hemodialysis center at Bordeaux University Hospital, an analysis of the microorganisms causing all catheter-related bloodstream infection over the period 2018-2020 enabled us to propose, in agreement with the infectious disease specialists, an adapted probabilistic antibiotic therapy protocol. This approach allowed us to observe a low incidence of meticillinoresistance of Staphylococcus. For catheters inserted more than 6 months ago, we observed no Staphylococcus, no multi-resistant Pseudomonas, and only 2% of Enterobacteria resistant to cephalosporins. A frequent updating of the microbiological epidemiology of catheter-related bloodstream infection, in partnership with the infectious diseases team in each hemodialysis center, allowing an adaptation of the probabilistic antibiotic therapy, and seems to have a good feasibility. This strategy might favor the preservation of microbial ecology on an individual and collective scale in maintenance hemodialysis patients.
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Affiliation(s)
- Mathieu Acquier
- Service de néphrologie-transplantation-dialyse-aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Valérie De Précigout
- Service de néphrologie-transplantation-dialyse-aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Yahsou Delmas
- Service de néphrologie-transplantation-dialyse-aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Véronique Dubois
- Laboratoire de bactériologie, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Fatima M'Zali
- UMR 5234 CNRS, université de Bordeaux, 33000 Bordeaux, France
| | - Arnaud Zabala
- UMR 5234 CNRS, université de Bordeaux, 33000 Bordeaux, France
| | - Renaud De-La-Faille
- Service de néphrologie-transplantation-dialyse-aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Sébastien Rubin
- Service de néphrologie-transplantation-dialyse-aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France
| | - Charles Cazanave
- Service de maladies infectieuses et tropicales, hôpital Pellegrin, CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Mathilde Puges
- Service de maladies infectieuses et tropicales, hôpital Pellegrin, CHU de Bordeaux, place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Christian Combe
- Service de néphrologie-transplantation-dialyse-aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France; Unité Inserm 1026 Biotis, université de Bordeaux, 33000 Bordeaux, France
| | - Hannah Kaminski
- Service de néphrologie-transplantation-dialyse-aphérèses, hôpital Pellegrin, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France; CNRS-UMR 5164 ImmunoConcEpT, université de Bordeaux, 33076 Bordeaux, France.
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4
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Maharaj AR, Wu H, Zimmerman KO, Muller WJ, Sullivan JE, Sherwin CMT, Autmizguine J, Rathore MH, Hornik CD, Al-Uzri A, Payne EH, Benjamin DK, Hornik CP. Pharmacokinetics of Ceftazidime in Children and Adolescents with Obesity. Paediatr Drugs 2021; 23:499-513. [PMID: 34302290 PMCID: PMC9706343 DOI: 10.1007/s40272-021-00460-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this study was to evaluate ceftazidime pharmacokinetics (PK) in a cohort that includes a predominate number of children and adolescents with obesity and assess the efficacy of competing dosing strategies. METHODS A population PK model was developed using opportunistically collected plasma samples. For each dosing strategy, model-based probability of target attainment (PTA) estimates were computed for study participants using empirical Bayes estimates. In addition, the effects of body size and renal function on PTA were evaluated using stochastic model simulations with virtually generated subjects. RESULTS Twenty-nine participants, 24 of whom were obese, contributed data towards the analysis. The median (range) age, body weight, and body mass index of participants were 12.2 years (2.3-20.6), 59.2 kg (8.4-121), and 25.2 kg/m2 (13.8-42.9), respectively. Administration of 50 mg/kg intravenously (IV) every 8 hours (q8h; max 6 g/day) or 40 mg/kg IV q6h (max 6 g/day) resulted in PTA values of ≥ 90% (minimum inhibitory concentration 8 mg/L) for the subset of obese participants with estimated glomerular filtration rates (GFR) ≥ ~ 80 mL/min/1.73 m2. However, for both regimens, stochastic model simulations denoted lower PTA values (< 90%) with increasing body weight for virtual subjects with GFR ≥ 120 mL/min/1.73 m2. Alternatively, permitting for a maximum daily dose of 8 g/day using a 40 mg/kg IV q6h regimen provided PTA values that were near or above target (90%) for virtual subjects between 10 to 120 kg with GFR ≥ 80 mL/min/1.73 m2. CONCLUSION Our analysis suggests administration of 40 mg/kg IV q6h (max 8 g/day) maximizes PTA in children and adolescents with obesity and GFR ≥ 80 mL/min/1.73 m2. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01431326.
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Affiliation(s)
- Anil R Maharaj
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
| | - Kanecia O Zimmerman
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - William J Muller
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University, Chicago, IL, USA
| | - Janice E Sullivan
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, OH, USA
| | - Julie Autmizguine
- Department of Pharmacology and Pediatrics, Research Center, CHU Sainte-Justine, Montreal, QC, Canada
| | - Mobeen H Rathore
- Division of Pediatric Infectious Diseases and Immunology, University of Florida Center for HIV/AIDS Research, Education, and Service, Wolfson Children's Hospital, Jacksonville, FL, USA
| | - Chi D Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Amira Al-Uzri
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | | | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, 300 West Morgan Street, Box 3850, Durham, NC, 27701, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
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5
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Cimino C, Burnett Y, Vyas N, Norris AH. Post-Dialysis Parenteral Antimicrobial Therapy in Patients Receiving Intermittent High-Flux Hemodialysis. Drugs 2021; 81:555-574. [PMID: 33591549 PMCID: PMC7884963 DOI: 10.1007/s40265-021-01469-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 11/24/2022]
Abstract
Patients with end-stage renal disease (ESRD) requiring intermittent hemodialysis (IHD) are at increased risk of infection, which represents a leading cause of mortality in this population. The use of additional vascular access devices such as peripherally inserted central catheters to treat such infections should be minimized in patients with ESRD requiring IHD in order to mitigate complications such as infection and thrombosis and to maintain venous patency for hemodialysis access. Intravenous antimicrobial dosing following IHD has the advantages of avoiding additional access devices and providing convenience for patients and providers. Vancomycin, cefazolin, and aminoglycosides have historically been regarded as the primary intravenous antimicrobials administered with IHD given their relatively low cost, convenient dosing, and longevity of clinical use. Despite this, a growing body of literature is evaluating the use of an expanded list of antimicrobials that may be employed using post-dialysis dosing for patients requiring IHD; however, the available data are largely limited to pharmacokinetic studies and small cohorts of infected patients or uninfected subjects. Post-dialytic dosing of intravenous antimicrobials may be considered on a patient-by-patient basis after careful consideration of clinical, microbiological, and logistical factors that may influence the probability of treatment success. This document reviews and evaluates currently available information on the post-dialytic administration of an expanded list of intravenous antimicrobials in the setting of thrice-weekly, high-flux IHD.
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Affiliation(s)
- Christo Cimino
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA.
| | - Yvonne Burnett
- St. Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis, 1 Pharmacy Place, St. Louis, MO, 63110, USA.,Department of Pharmacy, Missouri Baptist Medical Center, 3015 N Ballas Road, St. Louis, MO, 63131, USA
| | - Nikunj Vyas
- Department of Pharmacy, Jefferson Health-New Jersey, Stratford, NJ, 08084, USA
| | - Anne H Norris
- Perelman School of Medicine, University of Pennsylvania, 51 N. 39th Street, Philadelphia, PA, 19104, USA
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Maxwell-Scott H, Thangarajah R, Arnold A, Wade P, Klein JL. Successful treatment of Pseudomonas aeruginosa infective endocarditis via haemodialysis outpatient parenteral antimicrobial therapy: case report. J Antimicrob Chemother 2020; 74:1757-1759. [PMID: 30830217 DOI: 10.1093/jac/dkz096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Hector Maxwell-Scott
- Department of Infection, Guy's and St Thomas' Hospital, 5th Floor North Wing, Westminster Bridge Road, London, UK
| | - Rajeni Thangarajah
- Department of Infection, Guy's and St Thomas' Hospital, 5th Floor North Wing, Westminster Bridge Road, London, UK
| | - Amber Arnold
- Department of Infection, Guy's and St Thomas' Hospital, 5th Floor North Wing, Westminster Bridge Road, London, UK
| | - Paul Wade
- Department of Infection, Guy's and St Thomas' Hospital, 5th Floor North Wing, Westminster Bridge Road, London, UK
| | - John L Klein
- Department of Infection, Guy's and St Thomas' Hospital, 5th Floor North Wing, Westminster Bridge Road, London, UK
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7
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Zhuang L, Yu Y, Wei X, Florian J, Jang SH, Reynolds KS, Wang Y. Evaluation of Hemodialysis Effect on Pharmacokinetics of Meropenem/Vaborbactam in End-Stage Renal Disease Patients Using Modeling and Simulation. J Clin Pharmacol 2020; 60:1011-1021. [PMID: 32149406 DOI: 10.1002/jcph.1595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/27/2020] [Indexed: 11/08/2022]
Abstract
The objectives of this study were to evaluate the effect of hemodialysis (HD) on the pharmacokinetics (PK) of meropenem/vaborbactam, an approved beta-lactam/beta-lactamase inhibitor combination, and provide the rationale for the recommended timing of meropenem/vaborbactam administration relative to HD in end-stage renal disease (ESRD) patients. Population PK models were developed separately for meropenem and vaborbactam in subjects with normal renal function and different degrees of renal impairment, including those receiving HD. Simulations were performed to evaluate the exposure of meropenem and vaborbactam in ESRD patients who received a fixed dose of 0.5 g/0.5 g meropenem/vaborbactam every 12 hours as a 3-hour intravenous infusion under various drug administration schedules relative to HD. The probability of target attainment (PTA) analyses were conducted with pharmacokinetic/pharmacodynamic (PK/PD) targets of meropenem and vaborbactam. Simulations showed that HD reduces the accumulation of vaborbactam, but the exposure of vaborbactam is still above the PK/PD target regardless of whether meropenem/vaborbactam is administered predialysis or postdialysis. For meropenem, drug infusion completed right prior to initiation of HD may substantially reduce exposure leading to poor PTA results. In contrast, drug infusion completed at least 2 hours prior to initiation of HD is not predicted to result in efficacy loss based on PTA analysis. The results of simulation indicate that meropenem/vaborbactam infusion completed at least 2 hours prior to initiation of HD or administered immediately after the end of HD can avoid potential efficacy loss in ESRD patients.
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Affiliation(s)
- Luning Zhuang
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland, USA
| | - Yichao Yu
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland, USA.,Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Xiaohui Wei
- Division of Clinical Pharmacology IV, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland, USA
| | - Jeffry Florian
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland, USA
| | - Seong H Jang
- Division of Clinical Pharmacology IV, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland, USA
| | - Kellie S Reynolds
- Division of Clinical Pharmacology IV, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland, USA
| | - Yaning Wang
- Division of Pharmacometrics, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Springs, Maryland, USA
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Evaluation of Fetal and Maternal Vancomycin-Induced Kidney Injury during Pregnancy in a Rat Model. Antimicrob Agents Chemother 2019; 63:AAC.00761-19. [PMID: 31332061 DOI: 10.1128/aac.00761-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/11/2019] [Indexed: 12/18/2022] Open
Abstract
Previous literature suggests that maternal vancomycin crosses the placental barrier to the fetus. Further, early animal studies indicated that kidney injury was not observed in the progeny. These studies were conducted prior to the availability of sensitive biomarkers for kidney injury. Therefore, a previous finding of no renal damage to the infant may be misleading. Vancomycin was administered intravenously to pregnant rats at a dose of 250 mg/kg of body weight/day (N = 6 per trimester) on three consecutive gestational days (GD) during trimesters 1, 2, and 3 (T1, T2, and T3, respectively) in three independent cohorts. The dams carried to term and delivered vaginally on GD 21. Kidneys were harvested from dams and pups and homogenized. Samples were prepared by protein precipitation and injected in a liquid chromatography tandem mass spectrometer, and vancomycin was quantified. The kidney tissue homogenate from dams and pups were analyzed for kidney injury molecule-1 (KIM-1). As trimesters progressed, the quantity of vancomycin increased linearly in the kidneys of both rat dams and pups (P < 0.0001 for T1 and T3, P < 0.0001 for T2 and T3, and P < 0.0001 for T3 and T3 control for both rat dams and pups). KIM-1 concentrations in pup kidneys were significantly higher when dams were administered vancomycin in trimesters 1 (P = 0.0001) and 2 (P = 0.0024) than in controls in trimester 3. Data demonstrate persistence of vancomycin in maternal and rat pup kidneys in all three trimesters of pregnancy with associated damage to the kidney, as indicated by expression of KIM-1.
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9
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Hoff BM, Maker JH, Dager WE, Heintz BH. Antibiotic Dosing for Critically Ill Adult Patients Receiving Intermittent Hemodialysis, Prolonged Intermittent Renal Replacement Therapy, and Continuous Renal Replacement Therapy: An Update. Ann Pharmacother 2019; 54:43-55. [PMID: 31342772 DOI: 10.1177/1060028019865873] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objective: To summarize current antibiotic dosing recommendations in critically ill patients receiving intermittent hemodialysis (IHD), prolonged intermittent renal replacement therapy (PIRRT), and continuous renal replacement therapy (CRRT), including considerations for individualizing therapy. Data Sources: A literature search of PubMed from January 2008 to May 2019 was performed to identify English-language literature in which dosing recommendations were proposed for antibiotics commonly used in critically ill patients receiving IHD, PIRRT, or CRRT. Study Selection and Data Extraction: All pertinent reviews, selected studies, and references were evaluated to ensure appropriateness for inclusion. Data Synthesis: Updated empirical dosing considerations are proposed for antibiotics in critically ill patients receiving IHD, PIRRT, and CRRT with recommendations for individualizing therapy. Relevance to Patient Care and Clinical Practice: This review defines principles for assessing renal function, identifies RRT system properties affecting drug clearance and drug properties affecting clearance during RRT, outlines pharmacokinetic and pharmacodynamic dosing considerations, reviews pertinent updates in the literature, develops updated empirical dosing recommendations, and highlights important factors for individualizing therapy in critically ill patients. Conclusions: Appropriate antimicrobial selection and dosing are vital to improve clinical outcomes. Dosing recommendations should be applied cautiously with efforts to consider local epidemiology and resistance patterns, antibiotic dosing and infusion strategies, renal replacement modalities, patient-specific considerations, severity of illness, residual renal function, comorbidities, and patient response to therapy. Recommendations provided herein are intended to serve as a guide in developing and revising therapy plans individualized to meet a patient's needs.
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Affiliation(s)
- Brian M Hoff
- Northwestern Memorial Hospital, Chicago, IL, USA
| | - Jenana H Maker
- University of the Pacific Thomas J. Long School of Pharmacy and Health Sciences, Stockton, CA, USA.,University of California Davis Medical Center, Sacramento, CA, USA
| | - William E Dager
- University of California Davis Medical Center, Sacramento, CA, USA
| | - Brett H Heintz
- University of Iowa College of Pharmacy, Iowa City, IA, USA.,Iowa City Veterans Affairs (VA) Health Care System, Iowa City, IA, USA
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10
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Abstract
Antimicrobial pharmacology and its effect on prescribing is quite complex. Selecting an antibiotic that will optimally treat an infection while minimizing adverse effects and the development of resistance is only the first step, as one must also consider the patient's individual pharmacokinetic alterations and the pharmacodynamic properties of the drug when prescribing it as well. Patients with CKD may have alterations in their protein binding, volumes of distribution, kidney clearance, and nonrenal clearance that necessitates antibiotic dose adjustments to prevent the development of toxicity. Knowledge of a drug's pharmacodynamics, defined as the relationship between drug exposure and antibacterial efficacy, provides some guidance regarding the optimal way to make dose adjustments. Different pharmacodynamic goals, such as maximizing the time that free (unbound) drug concentrations spend above the minimum inhibitory concentration (MIC) for time dependent drugs (e.g., β-lactams) or maximizing the free peak-to-MIC ratio for concentration-dependent antibiotics (e.g., aminoglycosides), require different adjustment strategies; for instance, decreasing the dose while maintaining normal dosing frequency or giving normal (or even larger) doses less frequently, respectively. Patients receiving hemodialysis have other important prescribing considerations as well. The nephrologist or patient may prefer to receive antibiotics that can be administered intravenously toward the end of a dialysis session. Additionally, newer dialysis technologies and filters can increase drug removal more than originally reported. This review will discuss the place in therapy, mechanism of action, pharmacokinetic, pharmacodynamic, and other pharmacologic considerations encountered when prescribing commonly used antibiotics in patients with chronic kidney disease or ESKD.
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Affiliation(s)
- Rachel F Eyler
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, Connecticut; and .,Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, Connecticut
| | - Kristina Shvets
- Department of Pharmacy Services, Yale-New Haven Hospital, New Haven, Connecticut
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11
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Simplified Aztreonam Dosing in Patients with End-Stage Renal Disease: Results of a Monte Carlo Simulation. Antimicrob Agents Chemother 2018; 62:AAC.01066-18. [PMID: 30150467 DOI: 10.1128/aac.01066-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/19/2018] [Indexed: 11/20/2022] Open
Abstract
The manufacturer-recommended aztreonam dosing for patients with creatinine clearance values of <10 ml/min/1.73 m2 is complex. It is not known whether simpler posthemodialysis dosing administered once daily or thrice weekly can reliably achieve pharmacodynamic goals. We found that 1 or 2 g administered once daily after hemodialysis had >90% probability of target attainment up to MICs of 4 or 8 mg/liter, respectively. Thrice-weekly dosing should generally be avoided, except in nonsevere infections with MICs of ≤0.5 mg/liter.
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12
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Population Pharmacokinetics and Dosing Optimization of Ceftazidime in Infants. Antimicrob Agents Chemother 2018; 62:AAC.02486-17. [PMID: 29378703 DOI: 10.1128/aac.02486-17] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 01/25/2018] [Indexed: 11/20/2022] Open
Abstract
Ceftazidime, a third-generation cephalosporin, can be used for the treatment of adults and children with infections due to susceptible bacteria. To date, the pediatric pharmacokinetic data are limited in infants, and therefore we aimed to evaluate the population pharmacokinetics of ceftazidime in infants and to define the appropriate dose to optimize ceftazidime treatment. Blood samples were collected from children treated with ceftazidime, and concentrations of the drug were quantified by high-performance liquid chromatography with UV detection (HPLC-UV). A population pharmacokinetic analysis was performed using NONMEM software (version 7.2.0). Fifty-one infants (age range, 0.1 to 2.0 years) were included. Sparse pharmacokinetic samples (n = 90) were available for analysis. A one-compartment model with first-order elimination showed the best fit with the data. A covariate analysis identified that body weight and creatinine clearance (CLCR) were significant covariates influencing ceftazidime clearance. Monte Carlo simulation demonstrated that the currently used dosing regimen of 50 mg/kg twice daily was associated with a high risk of underdosing in infants. In order to reach the target of 70% of the time that the free antimicrobial drug concentration exceeds the MIC (fT>MIC), 25 mg/kg every 8 h (q8h) and 50 mg/kg q8h were required for MICs of 4 and 8 mg/liter, respectively. The population pharmacokinetic characteristics of ceftazidime were evaluated in infants. An evidence-based dosing regimen was established based on simulation.
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Wang H, Li X, Sun S, Mao G, Xiao P, Fu C, Liang Z, Zheng M, Huang Y, Tang H, Ou R, Yang N, Ling X, Zhao Z. Population Pharmacokinetics and Dosing Simulations of Ceftazidime in Chinese Neonates. J Pharm Sci 2017; 107:1416-1422. [PMID: 29274818 DOI: 10.1016/j.xphs.2017.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 12/05/2017] [Accepted: 12/14/2017] [Indexed: 11/17/2022]
Abstract
An accurate dosage determination is required in neonates when antibiotics are used. The adult data cannot be simply extrapolated to the pediatric population due to significant individual differences. We aimed to identify factors impacting ceftazidime exposure in neonates and to provide drug dosing guidance to clinicians. Forty-three neonates aged less than 60 days with proven or suspected infections were enrolled in this study. After intravenous administration, blood samples were collected, and plasma ceftazidime concentration was determined using a HPLC method. Pharmacokinetic data were fitted using a nonlinear mixed-effects model approach. One-compartmental model could nicely characterize the ceftazidime in vivo behavior. The covariate test found that the postmenstrual age (day) was strongly associated with systemic drug clearance (L/h), and the effect of body weight (kg) was identified as the covariate on distribution volume (L). Compared with the base model, the addition of covariates improved the goodness-of-fit of the final model. Model validation (bootstrap, visual predictive check, and prediction-corrected visual predictive check) suggested a robust and reliable pharmacokinetic model was developed. Personalized dosage regimens were provided based on model simulations. The intravenous dose should be adjusted according to postmenstrual age, body weight, and minimum inhibitory concentration.
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Affiliation(s)
- Honghong Wang
- Department of Pharmacy, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Xingang Li
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Precision Medicine Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shusen Sun
- College of Pharmacy and Health Sciences, Western New England University, Springfield, Massachusetts 01119
| | - Guifu Mao
- Department of Pharmacy, Liuzhou Traditional Chinese Medical Hospital, Guangxi, China
| | - Ping Xiao
- Department of Pharmacy, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Chan Fu
- Department of Neonatology, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Zhuoxin Liang
- Department of Critical Care Medicine, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Min Zheng
- Department of Pediatric, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Yuling Huang
- Department of Pharmacy, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Haihong Tang
- Department of Neonatology, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Renhao Ou
- Department of Pharmacy, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Ni Yang
- Department of Pharmacy, Liuzhou Maternity and Child Care Hospital, Guangxi, China
| | - Xi Ling
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Precision Medicine Research Center for Neurological Disorders, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Effects of Clinically Meaningful Concentrations of Antipseudomonal β-Lactams on Time to Detection and Organism Growth in Blood Culture Bottles. J Clin Microbiol 2017; 55:3502-3512. [PMID: 29021155 DOI: 10.1128/jcm.01241-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 09/18/2017] [Indexed: 12/16/2022] Open
Abstract
The effectiveness of antimicrobial binding resins present in blood culture (BC) bottles in removing meropenem, ceftolozane-tazobactam, and ceftazidime-avibactam is unknown. We assessed the time to detection (TTD) and growth of 2 Pseudomonas aeruginosa isolates in the presence of clinically meaningful concentrations of these antibiotics. Bactec Plus Aerobic/F and BacT/Alert FA Plus BC bottles were inoculated with one of two isolates (1 meropenem susceptible and 1 resistant), followed by fresh whole blood containing the peak, midpoint, or trough plasma concentrations for meropenem, ceftolozane-tazobactam, and ceftazidime-avibactam. Matching bottles were loaded into their respective detection instruments and a standard incubator at 37°C, with TTD and CFU being monitored for up to 72 h. Bacterial growth was observed for 11/48 (22.9%), 22/48 (45.8%), and 47/48 (97.9%) of all BC bottles inoculated with the peak, midpoint, and trough concentrations, respectively (P ≤ 0.001). When P. aeruginosa was isolated, the TTD was typically <26 h, and no differences between Bactec and BacT/Alert bottles were observed. In both systems, meropenem was removed to a greater degree than were ceftolozane and ceftazidime; however, concentrations for all antibiotics remained above the MIC for the susceptible organisms at 12 h. BC bottles containing antibiotic binding resins may not sufficiently inactivate achievable concentrations of meropenem, ceftolozane-tazobactam, and ceftazidime-avibactam. The consistent identification of both P. aeruginosa isolates was observed only in the presence of antibiotic trough concentrations. To minimize false-negative BC results for patients already receiving these antibiotics, cultures should be collected just prior to the next dose, when antibiotic concentrations are lowest.
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Rhodes NJ, Prozialeck WC, Lodise TP, Venkatesan N, O'Donnell JN, Pais G, Cluff C, Lamar PC, Neely MN, Gulati A, Scheetz MH. Evaluation of Vancomycin Exposures Associated with Elevations in Novel Urinary Biomarkers of Acute Kidney Injury in Vancomycin-Treated Rats. Antimicrob Agents Chemother 2016; 60:5742-51. [PMID: 27431226 PMCID: PMC5038238 DOI: 10.1128/aac.00591-16] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/26/2016] [Indexed: 11/20/2022] Open
Abstract
Vancomycin has been associated with acute kidney injury (AKI). However, the pharmacokinetic/toxicodynamic relationship for AKI is not well defined. Allometrically scaled vancomycin exposures were used to assess the relationship between vancomycin exposure and AKI. Male Sprague-Dawley rats received clinical-grade vancomycin in normal saline (NS) as intraperitoneal (i.p.) injections for 24- to 72-h durations with doses ranging 0 to 200 mg/kg of body weight divided once or twice daily. Urine was collected over the protocol's final 24 h. Renal histopathology was qualitatively scored. Urinary biomarkers (e.g., cystatin C, clusterin, kidney injury molecule 1 [KIM-1], osteopontin, lipocalin 2/neutrophil gelatinase-associated lipocalin 2) were assayed using a Luminex xMAP system. Plasma vancomycin concentrations were assayed by high-performance liquid chromatography with UV detection. A three-compartment vancomycin pharmacokinetic model was fit to the data with the Pmetrics package for R. The exposure-response in the first 24 h was evaluated using Spearman's nonparametric correlation coefficient (rs) values for the area under the concentration-time curve during the first 24 h (AUC0-24), the maximum concentration in plasma during the first 24 h (Cmax0-24 ), and the lowest (minimum) concentration in plasma after the dose closest to 24 h (Cmin0-24 ). A total of 52 rats received vancomycin (n = 42) or NS (n = 10). The strongest exposure-response correlations were observed between AUC0-24 and Cmax0-24 and urinary AKI biomarkers. Exposure-response correlations (rs values) for AUC0-24, Cmax0-24 , and Cmin0-24 were 0.37, 0.39, and 0.22, respectively, for clusterin; 0.42, 0.45, and 0.26, respectively, for KIM-1; and 0.52, 0.55, and 0.42, respectively, for osteopontin. However, no differences in histopathological scores were observed. Optimal sampling times after administration of the i.p. dose were 0.25, 0.75, 2.75, and 8 h for the once-daily dosing schemes and 0.25, 1.25, 14.5, and 17.25 h for the twice-daily dosing schemes. Our observations suggest that AUC0-24 or Cmax0-24 correlates with increases in urinary AKI biomarkers.
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Affiliation(s)
- Nathaniel J Rhodes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Walter C Prozialeck
- Department of Pharmacology, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois, USA
| | - Thomas P Lodise
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, New York, USA
| | - Natarajan Venkatesan
- Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA
| | - J Nicholas O'Donnell
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA
| | - Gwendolyn Pais
- Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA
| | - Cameron Cluff
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA
| | - Peter C Lamar
- Department of Pharmacology, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois, USA
| | - Michael N Neely
- University of Southern California, Keck School of Medicine, Los Angeles, California, USA Laboratory of Applied Pharmacokinetics and Bioinformatics (LAPKB), Children's Hospital of Los Angeles Saban Research Institute, Los Angeles, California, USA
| | - Anil Gulati
- Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
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O'Donnell JN, O'Donnell EP, Kumar EJ, Lavhale MS, Andurkar SV, Gulati A, Scheetz MH. Pharmacokinetics of centhaquin citrate in a dog model. ACTA ACUST UNITED AC 2016; 68:803-9. [PMID: 27109141 DOI: 10.1111/jphp.12554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/13/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Centhaquin citrate is a novel agent that is being developed for use in the resuscitation of patients with haemorrhagic shock. While pharmacokinetics have been described in small animal models, the pharmacokinetic parameters of centhaquin citrate in large mammals have yet to be described. METHODS Four healthy Beagle dogs (two males and two females) were given an intravenous bolus of 1.0 mg/kg centhaquin citrate. Plasma concentrations were measured at baseline and at ten time points within 24 h after administration. Multiple compartmental models were built and compared. The nonparametric adaptive grid function within the Pmetrics package for R was used for parameter estimation. Predicted concentrations were calculated using population mean and individual Bayesian posterior parameters. KEY FINDINGS Centhaquin citrate pharmacokinetic parameters were best described using a two-compartment model. Median (IQR) values for Ke , Vc , Vp , Kcp and Kpc were 4.9 (4.4-5.2) h(-1) , 328.4 (304.0-331.9) l, 1000.6 (912.3-1042.4) l, 10.6 (10.3-11.1) h(-1) and 3.2 (2.9-3.7) h(-1) , respectively. CONCLUSIONS Pharmacokinetic parameters of centhaquin citrate in a large mammal have been described. A large volume of distribution and rapid elimination were observed, consistent with previous work in rats.
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Affiliation(s)
- J Nicholas O'Donnell
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - E Paul O'Donnell
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - E Jeevan Kumar
- Pharmazz Research Center, Pharmazz India Private Limited, Greater Noida, India
| | - Manish S Lavhale
- Pharmazz Research Center, Pharmazz India Private Limited, Greater Noida, India
| | - Shridhar V Andurkar
- Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Anil Gulati
- Department of Pharmaceutical Sciences, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
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Sime FB, Roberts JA. Antibiotic Dosing In Critically Ill Patients Receiving Renal Replacement Therapy. Expert Rev Clin Pharmacol 2016; 9:497-499. [PMID: 26677734 DOI: 10.1586/17512433.2016.1133290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Fekade Bruck Sime
- a Burns, Trauma & Critical Care Research Centre , The University of Queensland , Brisbane , Queensland , Australia.,b Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - Jason A Roberts
- a Burns, Trauma & Critical Care Research Centre , The University of Queensland , Brisbane , Queensland , Australia.,b Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool , UK.,c Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,d Pharmacy Department , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,e School of Pharmacy , The University of Queensland , Brisbane , Queensland , Australia
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18
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O'Donnell JN, Gulati A, Lavhale MS, Sharma SS, Patel AJ, Rhodes NJ, Scheetz MH. Pharmacokinetics of centhaquin citrate in a rat model. ACTA ACUST UNITED AC 2016; 68:56-62. [PMID: 26725913 DOI: 10.1111/jphp.12498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 10/17/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Centhaquin citrate is a novel agent being developed for use in the treatment of haemorrhagic shock. It has decreased mortality in rat, rabbit and pig models of hypovolaemic shock compared to hypertonic saline and lactated Ringer's resuscitation. The pharmacokinetics of centhaquin citrate have not been described to date. METHODS Sixteen male Sprague Dawley rats were given an intravenous bolus of 0.45 mg/kg centhaquin citrate. Rats were divided into two groups; plasma concentrations were measured at five time points for each group within 24 h after administration. Competing compartmental pharmacokinetic models were assessed. The nonparametric adaptive grid function within the Pmetrics package for R was used for parameter estimation. Predicted concentrations were calculated using population median and individual Bayesian posterior parameters. KEY FINDINGS A two-compartment model of centhaquin citrate best fit the data. Median (IQR) values for elimination coefficient (Ke), volume of distribution (V) and intercompartmental transfer rates (Kcp, Kpc) were 8.8 (5.2-12.8) h(-1), 6.4 (2.8-10.4) l, 11.9 (4.6-15.0) h(-1) and 3.7 (2.3-9.1) h(-1), respectively. CONCLUSION This is the first report of the pharmacokinetic parameters of centhaquin citrate in a rat model. Centhaquin citrate was found to have a short half-life with a large volume of distribution.
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Affiliation(s)
- J Nicholas O'Donnell
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Department of Pharmacy, Northwestern Memorial Hospital, Chicago
| | - Anil Gulati
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Manish S Lavhale
- Pharmazz Research Center, Pharmazz India Private Limited, Greater Noida, UP, India
| | - Shyam S Sharma
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), S.A.S. Nagar, Punjab, India
| | - Arjun J Patel
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), S.A.S. Nagar, Punjab, India
| | - Nathaniel J Rhodes
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Department of Pharmacy, Northwestern Memorial Hospital, Chicago
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove, IL, USA.,Department of Pharmacy, Northwestern Memorial Hospital, Chicago
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Rhodes NJ, Kuti JL, Nicolau DP, Neely MN, Nicasio AM, Scheetz MH. An exploratory analysis of the ability of a cefepime trough concentration greater than 22 mg/L to predict neurotoxicity. J Infect Chemother 2015; 22:78-83. [PMID: 26712584 DOI: 10.1016/j.jiac.2015.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/20/2015] [Accepted: 10/21/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Cefepime trough concentrations >22 mg/L (T(>22)) have been associated with neurotoxicity in a single study. PATIENTS AND METHODS Neurotoxicity outcomes for 28 cefepime-treated adult patients with febrile neutropenia were abstracted from the literature. The precision of T(>22) to predict neurotoxicity was quantified using 95% confidence intervals. Thirty-two cefepime-treated patients contributed serum concentrations for a pharmacokinetic model, fit using the Nonparametric Adaptive Grid algorithm within the Pmetrics package for R. Concentration-time curves were simulated for common dosing schemes and 3 renal dispositions. Probabilities of neurotoxicity and numbers needed to harm were calculated from simulations according to the proposed pharmacokinetic/toxicodynamic threshold of T(>22). Bayesian modeling was utilized to explore other pharmacokinetic parameters relationships with neurotoxicity. RESULTS The mean probability of neurotoxicity at T(>22) was 51.4% (95% CI: 16.4-85.0%). Among the schemes and renal dispositions simulated, the combination of cefepime 2 g every 8 h and a creatinine clearance of 60 mL/min produced the greatest probability of neurotoxicity (48.3%). Estimated numbers needed to harm according to T(>22) ranged from 2.1 to 18.5 persons. Explorations of maximal serum concentration and area under the curve demonstrated high levels of collinearity, making it impossible to identify trough concentrations as the driver of neurotoxicity. DISCUSSION T(>22) had low precision as a predictive neurotoxic threshold. When a neurotoxic threshold of T(>22) was assumed, projected neurotoxicity rates and numbers needed to harm greatly exceeded observed neurotoxicity rates in the general population and in high risk subpopulations. Other drug exposure metrics should be explored.
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Affiliation(s)
- Nathaniel J Rhodes
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Joseph L Kuti
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Michael N Neely
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA; Laboratory of Applied Pharmacokinetics and Bioinformatics (LAPKB), Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Anthony M Nicasio
- Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, IL, USA; Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.
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Goh JHF, Lee SY, Ooi ST, Lee Soon-U L, Hee KH, Renaud CJ. Post-hemodialysis dosing of 1 vs. 2 g of ceftazidime in anuric end-stage renal disease patients on low-flux dialysis and its pharmacodynamic implications on clinical use. Hemodial Int 2015; 20:253-60. [PMID: 26486806 DOI: 10.1111/hdi.12377] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Ceftazidime is a cost-effective antimicrobial against Gram-negative pathogens associated with sepsis in end-stage renal disease (ESRD) hemodialysis patients with potential for wider use with the advent of ceftazidime-avibactam. Dosing ceftazidime post-hemodialysis appears attractive and convenient, but limited in vivo data on pharmacodynamic efficacy (PE) attainment, defined as >70% of the interdialytic period drug concentrations exceed susceptible pathogens minimal inhibitory concentrations (MICs) (%TMIC), warrants further assessment. We therefore evaluated PE and tolerability of 1 against 2 g regime in anuric ESRD patients on low-flux hemodialysis. Two doses of 1 or 2 g ceftazidime were administered post-hemodialysis prior to 48- and 72-hour interdialytic intervals in ESRD inpatients without active infections. Peak and trough concentrations (mg/L) were assayed using a validated liquid chromatography-tandem mass spectrometry method. Proportion of patients achieving PE for known pathogens with MICs ≤ 8 mg/L and adverse effects were assessed. Six (43%) and eight (57%) adult patients received 1 and 2 g dose, respectively. Median (25th-75th percentile), peak, 48- and 72-hour trough ceftazidime concentrations were 78 (60-98) vs. 158 (128-196), 37 (23-37) vs. 49 (39-71), and 13 (12-20) vs. 26 (21-41) mg/L, respectively, resulting in 100% TMIC for both doses. One patient on the 1-g dose experienced mild pruritus. Reliable and safe PE attainment over both 48- and 72-hour interdialytic interval was achievable with 1 g of ceftazidime dosed post-hemodialysis. The 2 g dose was equally effective and well tolerated but may not be necessary. These findings need validation in non-anuric patients, high-flux hemodialysis, and during avibactam co-administration.
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Affiliation(s)
| | - Siok Ying Lee
- Department of Pharmacy, Khoo Teck Puat Hospital, Singapore
| | - Say Tat Ooi
- Department of Medicine, Infectious Diseases Division, Khoo Teck Puat Hospital, Singapore
| | | | - Kim-Hor Hee
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Claude J Renaud
- Department of Medicine, Nephrology Division, Khoo Teck Puat Hospital, Singapore
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Thrice-weekly temocillin administered after each dialysis session is appropriate for the treatment of serious Gram-negative infections in haemodialysis patients. Int J Antimicrob Agents 2015; 46:660-5. [PMID: 26603304 DOI: 10.1016/j.ijantimicag.2015.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/05/2015] [Accepted: 09/08/2015] [Indexed: 11/20/2022]
Abstract
In patients with end-stage renal disease (ESRD) treated with intermittent haemodialysis, a limited number of antibiotics have been studied for their suitability for parenteral administration after dialysis sessions only in a thrice-weekly regimen. Temocillin is a β-lactam antibiotic with a long half-live and enhanced activity against most Gram-negative bacteria, including extended-spectrum β-lactamase-producers, thus making it an ideal candidate for use in this setting. This study aimed to evaluate the reliability of thrice-weekly parenteral temocillin in haemodialysis patients by characterising the pharmacokinetics of total and free temocillin. Free and total temocillin concentrations were determined with a validated HPLC method in 448 samples derived from 48 administration cycles in 16 patients with ESRD treated with intermittent haemodialysis and temocillin. Pharmacokinetics were non-linear partly due to saturation in protein binding. Median clearance and half-life for the free drug during intradialysis and interdialysis periods were 113 mL/min vs. 26 mL/min and 3.6 h vs. 24 h, respectively, with dialysis extracting approximately one-half of the residual concentration. The free temocillin concentration remained >16 mg/L (MIC90 threshold for most Enterobacteriaceae) during 48%, 67% and 71% of the dosing interval for patients receiving 1 g q24h, 2 g q48h and 3 g q72h, respectively, suggesting appropriate exposure for the two latter therapeutic schemes. Temocillin administered on dialysis days only in a dosing schedule of 2 g q48h and 3 g q72h is appropriate for the treatment of serious and/or resistant Gram-negative infections in patients with ESRD undergoing intermittent haemodialysis. These doses are higher than those previously recommended.
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