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van der Veer MAA, de Haan TR, Franken LGW, Groenendaal F, Dijk PH, de Boode WP, Simons S, Dijkman KP, van Straaten HL, Rijken M, Cools F, Nuytemans DHGM, van Kaam AH, Bijleveld YA, Mathôt RAA. Predictive Performance of a Gentamicin Pharmacokinetic Model in Term Neonates with Perinatal Asphyxia Undergoing Controlled Therapeutic Hypothermia. Ther Drug Monit 2024; 46:376-383. [PMID: 38287875 PMCID: PMC11078285 DOI: 10.1097/ftd.0000000000001166] [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: 08/06/2023] [Accepted: 10/24/2023] [Indexed: 01/31/2024]
Abstract
BACKGROUND Model validation procedures are crucial when population pharmacokinetic (PK) models are used to develop dosing algorithms and to perform model-informed precision dosing. We have previously published a population PK model describing the PK of gentamicin in term neonates with perinatal asphyxia during controlled therapeutic hypothermia (TH), which showed altered gentamicin clearance during the hypothermic phase dependent on gestational age and weight. In this study, the predictive performance and generalizability of this model were assessed using an independent data set of neonates with perinatal asphyxia undergoing controlled TH. METHODS The external data set contained a subset of neonates included in the prospective observational multicenter PharmaCool Study. Predictive performance was assessed by visually inspecting observed-versus-predicted concentration plots and calculating bias and precision. In addition, simulation-based diagnostics, model refitting, and bootstrap analyses were performed. RESULTS The external data set included 323 gentamicin concentrations of 39 neonates. Both the model-building and external data set included neonates from multiple centers. The original gentamicin PK model predicted the observed gentamicin concentrations with adequate accuracy and precision during all phases of controlled TH. Model appropriateness was confirmed with prediction-corrected visual predictive checks and normalized prediction distribution error analyses. Model refitting to the merged data set (n = 86 neonates with 935 samples) showed accurate estimation of PK parameters. CONCLUSIONS The results of this external validation study justify the generalizability of the gentamicin dosing recommendations made in the original study for neonates with perinatal asphyxia undergoing controlled TH (5 mg/kg every 36 or 24 h with gestational age 36-41 and 42 wk, respectively) and its applicability in model-informed precision dosing.
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Affiliation(s)
- Marlotte A. A. van der Veer
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Timo R. de Haan
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Linda G. W. Franken
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- UMC Utrecht Brain Center, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Peter H. Dijk
- Division of Neonatology, Department of Pediatrics, University Medical Center Groningen, Beatrix Children's Hospital, University of Groningen, Groningen, the Netherlands
| | - Willem P. de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Sinno Simons
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Koen P. Dijkman
- Department of Neonatology, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | | | - Monique Rijken
- Department of Neonatology, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands; and
| | - Filip Cools
- Department of Neonatology, Vrije Universiteit Brussel, Brussels, Belgium
| | - Debbie H. G. M. Nuytemans
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Anton H. van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Yuma. A. Bijleveld
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ron A. A. Mathôt
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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2
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de Hoop-Sommen MA, van der Heijden JEM, Freriksen JJM, Greupink R, de Wildt SN. Pragmatic physiologically-based pharmacokinetic modeling to support clinical implementation of optimized gentamicin dosing in term neonates and infants: proof-of-concept. Front Pediatr 2023; 11:1288376. [PMID: 38078320 PMCID: PMC10702772 DOI: 10.3389/fped.2023.1288376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/02/2023] [Indexed: 02/12/2024] Open
Abstract
Introduction Modeling and simulation can support dosing recommendations for clinical practice, but a simple framework is missing. In this proof-of-concept study, we aimed to develop neonatal and infant gentamicin dosing guidelines, supported by a pragmatic physiologically-based pharmacokinetic (PBPK) modeling approach and a decision framework for implementation. Methods An already existing PBPK model was verified with data of 87 adults, 485 children and 912 neonates, based on visual predictive checks and predicted-to-observed pharmacokinetic (PK) parameter ratios. After acceptance of the model, dosages now recommended by the Dutch Pediatric Formulary (DPF) were simulated, along with several alternative dosing scenarios, aiming for recommended peak (i.e., 8-12 mg/L for neonates and 15-20 mg/L for infants) and trough (i.e., <1 mg/L) levels. We then used a decision framework to weigh benefits and risks for implementation. Results The PBPK model adequately described gentamicin PK. Simulations of current DPF dosages showed that the dosing interval for term neonates up to 6 weeks of age should be extended to 36-48 h to reach trough levels <1 mg/L. For infants, a 7.5 mg/kg/24 h dose will reach adequate peak levels. The benefits of these dose adaptations outweigh remaining uncertainties which can be minimized by routine drug monitoring. Conclusion We used a PBPK model to show that current DPF dosages for gentamicin in term neonates and infants needed to be optimized. In the context of potential uncertainties, the risk-benefit analysis proved positive; the model-informed dose is ready for clinical implementation.
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Affiliation(s)
- Marika A. de Hoop-Sommen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joyce E. M. van der Heijden
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jolien J. M. Freriksen
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Rick Greupink
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia N. de Wildt
- Division of Pharmacology and Toxicology, Department of Pharmacy, Radboud University Medical Center, Nijmegen, Netherlands
- Department for Intensive Care, Radboud University Medical Center, Nijmegen, Netherlands
- Intensive Care and Pediatric Surgery, Erasmus MC, Rotterdam, Netherlands
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3
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Črček M, Grabnar I, Zdovc JA, Grosek Š, Kos MK. External validation of population pharmacokinetic models of gentamicin in paediatric population from preterm newborns to adolescents. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2023; 73:175-194. [PMID: 37307377 DOI: 10.2478/acph-2023-0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 06/14/2023]
Abstract
The aim of this study was to externally validate the predictive performance of published population pharmacokinetic models of gentamicin in all paediatric age groups, from preterm newborns to adolescents. We first selected published population pharmacokinetic models of gentamicin developed in the paediatric population with a wide age range. The parameters of the literature models were then re-estimated using the PRIOR subroutine in NONMEM®. The predictive ability of the literature and the tweaked models was evaluated. Retrospectively collected data from a routine clinical practice (512 concentrations from 308 patients) were used for validation. The models with covariates characterising developmental changes in clearance and volume of distribution had better predictive performance, which improved further after re-estimation. The tweaked model by Wang 2019 performed best, with suitable accuracy and precision across the complete paediatric population. For patients treated in the intensive care unit, a lower proportion of patients would be expected to reach the target trough concentration at standard dosing. The selected model could be used for model-informed precision dosing in clinical settings where the entire paediatric population is treated. However, for use in clinical practice, the next step should include additional analysis of the impact of intensive care treatment on gentamicin pharmacokinetics, followed by prospective validation.
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Affiliation(s)
- Mateja Črček
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
| | - Iztok Grabnar
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
| | - Jurij Aguiar Zdovc
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
| | - Štefan Grosek
- 2University of Ljubljana, Faculty of Medicine, Department of Pediatrics 1000 Ljubljana, Slovenia
- 3University Medical Centre Ljubljana Division of Obstetrics and Gynecology, Department of Perinatology Neonatology Section, 1000 Ljubljana Slovenia
- 4University Medical Centre Ljubljana Division of Paediatrics, Department of Paediatric Intensive Therapy, 1000 Ljubljana, Slovenia
| | - Mojca Kerec Kos
- 1University of Ljubljana, Faculty of Pharmacy, Department of Biopharmacy and Pharmacokinetics, 1000 Ljubljana Slovenia
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4
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Evaluating and Improving Neonatal Gentamicin Pharmacokinetic Models Using Aggregated Routine Clinical Care Data. Pharmaceutics 2022; 14:pharmaceutics14102089. [PMID: 36297524 PMCID: PMC9609639 DOI: 10.3390/pharmaceutics14102089] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Model-informed precision dosing (MIPD) can aid dose decision-making for drugs such as gentamicin that have high inter-individual variability, a narrow therapeutic window, and a high risk of exposure-related adverse events. However, MIPD in neonates is challenging due to their dynamic development and maturation and by the need to minimize blood sampling due to low blood volume. Here, we investigate the ability of six published neonatal gentamicin population pharmacokinetic models to predict gentamicin concentrations in routine therapeutic drug monitoring from nine sites in the United State (n = 475 patients). We find that four out of six models predicted with acceptable levels of error and bias for clinical use. These models included known important covariates for gentamicin PK, showed little bias in prediction residuals over covariate ranges, and were developed on patient populations with similar covariate distributions as the one assessed here. These four models were refit using the published parameters as informative Bayesian priors or without priors in a continuous learning process. We find that refit models generally reduce error and bias on a held-out validation data set, but that informative prior use is not uniformly advantageous. Our work informs clinicians implementing MIPD of gentamicin in neonates, as well as pharmacometricians developing or improving PK models for use in MIPD.
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Zazo H, Lagarejos E, Prado-Velasco M, Sánchez-Herrero S, Serna J, Rueda-Ferreiro A, Martín-Suárez A, Calvo MV, Pérez-Blanco JS, Lanao JM. Physiologically-based pharmacokinetic modelling and dosing evaluation of gentamicin in neonates using PhysPK. Front Pharmacol 2022; 13:977372. [PMID: 36249803 PMCID: PMC9554458 DOI: 10.3389/fphar.2022.977372] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Each year, infections caused around the 25% of neonatal deaths. Early empirical treatments help to reduce this mortality, although optimized dosing regimens are still lacking. The aims were to develop and validate a gentamicin physiologically-based pharmacokinetic (PBPK) model and then potentially explore dosing regimens in neonates using pharmacokinetic and pharmacodynamic criteria. The PBPK model developed consisted of 2 flow-limited tissues: kidney and other tissues. It has been implemented on a new tool called PhysPK, which allows structure reusability and evolution as predictive engine in Model-Informed Precision Dosing (MIPD). Retrospective pharmacokinetic information based on serum levels data from 47 neonates with gestational age between 32 and 39 weeks and younger than one-week postnatal age were used for model validation. The minimal PBPK model developed adequately described the gentamicin serum concentration-time profile with an average fold error nearly 1. Extended interval gentamicin dosing regimens (6 mg/kg q36h and 6 mg/kg q48h for term and preterm neonates, respectively) showed efficacy higher than 99% with toxicity lower than 10% through Monte Carlo simulation evaluations. The gentamicin minimal PBPK model developed in PhysPK from literature information, and validated in preterm and term neonates, presents adequate predictive performance and could be useful for MIPD strategies in neonates.
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Affiliation(s)
- Hinojal Zazo
- Pharmaceutical Sciences Department, University of Salamanca, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Eduardo Lagarejos
- Pharmaceutical Sciences Department, University of Salamanca, Salamanca, Spain
| | - Manuel Prado-Velasco
- Multiscale Modelling in Bioengineering Research Group and Department of Graphic Engineering, University of Seville, Seville, Spain
| | | | - Jenifer Serna
- Simulation Department, Empresarios Agrupados Internacional S.A., Madrid, Spain
| | | | - Ana Martín-Suárez
- Pharmaceutical Sciences Department, University of Salamanca, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - M. Victoria Calvo
- Pharmaceutical Sciences Department, University of Salamanca, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Jonás Samuel Pérez-Blanco
- Pharmaceutical Sciences Department, University of Salamanca, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- *Correspondence: Jonás Samuel Pérez-Blanco, ; José M. Lanao,
| | - José M. Lanao
- Pharmaceutical Sciences Department, University of Salamanca, Salamanca, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- *Correspondence: Jonás Samuel Pérez-Blanco, ; José M. Lanao,
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6
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Hodiamont CJ, van den Broek AK, de Vroom SL, Prins JM, Mathôt RAA, van Hest RM. Clinical Pharmacokinetics of Gentamicin in Various Patient Populations and Consequences for Optimal Dosing for Gram-Negative Infections: An Updated Review. Clin Pharmacokinet 2022; 61:1075-1094. [PMID: 35754071 PMCID: PMC9349143 DOI: 10.1007/s40262-022-01143-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/04/2022]
Abstract
Gentamicin is an aminoglycoside antibiotic with a small therapeutic window that is currently used primarily as part of short-term empirical combination therapy. Gentamicin dosing schemes still need refinement, especially for subpopulations where pharmacokinetics can differ from pharmacokinetics in the general adult population: obese patients, critically ill patients, paediatric patients, neonates, elderly patients and patients on dialysis. This review summarizes the clinical pharmacokinetics of gentamicin in these patient populations and the consequences for optimal dosing of gentamicin for infections caused by Gram-negative bacteria, highlighting new insights from the last 10 years. In this period, several new population pharmacokinetic studies have focused on these subpopulations, providing insights into the typical values of the most relevant pharmacokinetic parameters, the variability of these parameters and possible explanations for this variability, although unexplained variability often remains high. Both dosing schemes and pharmacokinetic/pharmacodynamic (PK/PD) targets varied widely between these studies. A gentamicin starting dose of 7 mg/kg based on total body weight (or on adjusted body weight in obese patients) appears to be the optimal strategy for increasing the probability of target attainment (PTA) after the first administration for the most commonly used PK/PD targets in adults and children older than 1 month, including critically ill patients. However, evidence that increasing the PTA results in higher efficacy is lacking; no studies were identified that show a correlation between estimated or predicted PK/PD target attainment and clinical success. Although it is unclear if performing therapeutic drug monitoring (TDM) for optimization of the PTA is of clinical value, it is recommended in patients with highly variable pharmacokinetics, including patients from all subpopulations that are critically ill (such as elderly, children and neonates) and patients on intermittent haemodialysis. In addition, TDM for optimization of the dosing interval, targeting a trough concentration of at least < 2 mg/L but preferably < 0.5–1 mg/L, has proven to reduce nephrotoxicity and is therefore recommended in all patients receiving more than one dose of gentamicin. The usefulness of the daily area under the plasma concentration–time curve for predicting nephrotoxicity should be further investigated. Additionally, more research is needed on the optimal PK/PD targets for efficacy in the clinical situations in which gentamicin is currently used, that is, as monotherapy for urinary tract infections or as part of short-term combination therapy.
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Affiliation(s)
- Caspar J Hodiamont
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Annemieke K van den Broek
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Suzanne L de Vroom
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jan M Prins
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy and Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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7
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Samb A, Kruizinga M, Tallahi Y, van Esdonk M, van Heel W, Driessen G, Bijleveld Y, Stuurman R, Cohen A, van Kaam A, de Haan TR, Mathôt R. Saliva as a sampling matrix for therapeutic drug monitoring of gentamicin in neonates: A prospective population pharmacokinetic and simulation study. Br J Clin Pharmacol 2021; 88:1845-1855. [PMID: 34625981 PMCID: PMC9298055 DOI: 10.1111/bcp.15105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 11/30/2022] Open
Abstract
Aims Therapeutic drug monitoring (TDM) of gentamicin in neonates is recommended for safe and effective dosing and is currently performed by plasma sampling, which is an invasive and painful procedure. In this study, feasibility of a non‐invasive gentamicin TDM strategy using saliva was investigated. Methods This was a multicentre, prospective, observational cohort study including 54 neonates. Any neonate treated with intravenous gentamicin was eligible for the study. Up to eight saliva samples were collected per patient at different time‐points. Gentamicin levels in saliva were determined with liquid chromatography tandem mass‐spectrometry (LC–MS/MS). A population pharmacokinetic (PK) model was developed using nonlinear mixed‐effects modelling (NONMEM) to describe the relation between gentamicin concentrations in saliva and plasma. Monte Carlo simulations with a representative virtual cohort (n = 3000) were performed to evaluate the probability of target attainment with saliva versus plasma TDM. Results Plasma PK was adequately described with an earlier published model. An additional saliva compartment describing the salivary gentamicin concentrations was appended to the model with first‐order input (k13 0.023 h−1) and first‐order elimination (k30 0.169 h−1). Inter‐individual variability of k30 was 38%. Postmenstrual age (PMA) correlated negatively with both k13 and k30. Simulations demonstrated that TDM with four saliva samples was accurate in 81% of the simulated cases versus 94% when performed with two plasma samples and 87% when performed with one plasma sample. Conclusion TDM of gentamicin using saliva is feasible and the difference in precision between saliva and plasma TDM may not be clinically relevant, especially for premature neonates.
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Affiliation(s)
- Amadou Samb
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Matthijs Kruizinga
- Centre for Human Drug Research, Leiden, the Netherlands.,Juliana Children's Hospital, HAGA Teaching Hospital, The Hague, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands
| | - Younes Tallahi
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - Willemijn van Heel
- Juliana Children's Hospital, HAGA Teaching Hospital, The Hague, the Netherlands
| | - Gertjan Driessen
- Juliana Children's Hospital, HAGA Teaching Hospital, The Hague, the Netherlands.,Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Yuma Bijleveld
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Rik Stuurman
- Centre for Human Drug Research, Leiden, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands
| | - Adam Cohen
- Centre for Human Drug Research, Leiden, the Netherlands.,Leiden University Medical Centre, Leiden, the Netherlands
| | - Anton van Kaam
- Department of Neonatology, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Timo R de Haan
- Department of Neonatology, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ron Mathôt
- Department of Pharmacy and Clinical Pharmacology, Amsterdam UMC, Amsterdam, the Netherlands
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8
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Tu Q, Cotta M, Raman S, Graham N, Schlapbach L, Roberts JA. Individualized precision dosing approaches to optimize antimicrobial therapy in pediatric populations. Expert Rev Clin Pharmacol 2021; 14:1383-1399. [PMID: 34313180 DOI: 10.1080/17512433.2021.1961578] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction:Severe infections continue to impose a major burden on critically ill children and mortality rates remain stagnant. Outcomes rely on accurate and timely delivery of antimicrobials achieving target concentrations in infected tissue. Yet, developmental aspects, disease-related variables, and host factors may severely alter antimicrobial pharmacokinetics in pediatrics. The emergence of antimicrobial resistance increases the need for improved treatment approaches.Areas covered:This narrative review explores why optimization of antimicrobial therapy in neonates, infants, children, and adolescents is crucial and summarizes the possible dosing approaches to achieve antimicrobial individualization. Finally, we outline a roadmap toward scientific evidence informing the development and implementation of precision antimicrobial dosing in critically ill children.The literature search was conducted on PubMed using the following keywords: neonate, infant, child, adolescent, pediatrics, antimicrobial, pharmacokinetic, pharmacodynamic target, Bayes dosing software, optimizing, individualizing, personalizing, precision dosing, drug monitoring, validation, attainment, and software implementation. Further articles were sought from the references of the above searched articles.Expert opinion:Recently, technological innovations have emerged that enabled the development of individualized antimicrobial dosing approaches in adults. More work is required in pediatrics to make individualized antimicrobial dosing approaches widely operationalized in this population.
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Affiliation(s)
- Quyen Tu
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Menino Cotta
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sainath Raman
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Centre for Children's Health Research (CCHR), The University of Queensland, Brisbane, QLD, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Luregn Schlapbach
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, The University Children's Hospital Zurich, Switzerland
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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9
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Aleem S, Wohlfarth M, Cotten CM, Greenberg RG. Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit. Semin Perinatol 2020; 44:151326. [PMID: 33158599 PMCID: PMC7550069 DOI: 10.1016/j.semperi.2020.151326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Suspected or proven late onset sepsis, necrotizing enterocolitis, urinary tract infections, and ventilator associated pneumonia occurring after the first postnatal days contribute significantly to the total antibiotic exposures in neonatal intensive care units. The variability in definitions and diagnostic criteria in these conditions lead to unnecessary antibiotic use. The length of treatment and choice of antimicrobial agents for presumed and proven episodes also vary among centers due to a lack of supportive evidence and guidelines. Implementation of robust antibiotic stewardship programs can encourage compliance with appropriate dosages and narrow-spectrum regimens.
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Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | | | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA,Corresponding author at: Department of Pediatrics, Duke University, Durham, NC, USA
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10
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Ali FEM, Hassanein EHM, Bakr AG, El-Shoura EAM, El-Gamal DA, Mahmoud AR, Abd-Elhamid TH. Ursodeoxycholic acid abrogates gentamicin-induced hepatotoxicity in rats: Role of NF-κB-p65/TNF-α, Bax/Bcl-xl/Caspase-3, and eNOS/iNOS pathways. Life Sci 2020; 254:117760. [PMID: 32418889 DOI: 10.1016/j.lfs.2020.117760] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 02/07/2023]
Abstract
AIM The present study focused on the possible underlying protective mechanisms of UDCA against GNT-induced hepatic injury. METHODS For achieving this goal, adult male rats were allocated into 4 groups: normal control (received vehicle), GNT (100 mg/kg, i.p. for 8 days), UDCA (60 mg/kg, P.O. for 15 days), and GNT + UDCA (received UDCA for 15 days and GNT started from the 7th day and lasted for 8 days). RESULTS The results revealed that UDCA significantly improved GNT-induced hepatic injury, oxidative stress, apoptosis, and inflammatory response. Interestingly, UDCA inhibited apoptosis by marked down-regulation of the Bax gene, Caspase-3, and cleaved Caspase-3 protein expressions while the level of Bcl-xL gene significantly increased. Moreover, UDCA strongly inhibited the inflammatory response through the down-regulation of both NF-κB-p65 and TNF-α accompanied by IL-10 elevation. Furthermore, the obtained results ended with the restored of mitochondria function that confirmed by electron microscopy. Histological analysis showed that UDCA remarkably ameliorated the histopathological changes induced by GNT. SIGNIFICANCE UDCA may be a promising agent that can be used to prevent hepatotoxicity observed in GNT treatment. This effect could be attributed to, at least in part, the ability of UDCA to modulate NF-κB-p65/TNF-α, Bax/Bcl-xl/Caspase-3, and eNOS/iNOS signaling pathways.
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Affiliation(s)
- Fares E M Ali
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt.
| | - Emad H M Hassanein
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Adel G Bakr
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Ehab A M El-Shoura
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Dalia A El-Gamal
- Department of Histology and Cell Biology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Amany R Mahmoud
- Department of Human Anatomy and Embryology, Faculty of Medicine, Assiut University, Assiut, Egypt; Department of Anatomy, Unaizah College of Medicine, Qassim University, Unaizah Al Qassim Region, Saudi Arabia
| | - Tarek Hamdy Abd-Elhamid
- Department of Histology and Cell Biology, Faculty of Medicine, Assiut University, Assiut, Egypt
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11
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Crcek M, Zdovc J, Kerec Kos M. A review of population pharmacokinetic models of gentamicin in paediatric patients. J Clin Pharm Ther 2019; 44:659-674. [PMID: 31102287 DOI: 10.1111/jcpt.12850] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 03/18/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Gentamicin is often used for the treatment of Gram-negative infections. Due to pharmacokinetic variability in paediatric patients, appropriate dosing of gentamicin in the paediatric population is challenging. This article reviews published population pharmacokinetic models of gentamicin in paediatric patients, identifies covariates that significantly influence gentamicin pharmacokinetics, and determines whether there is a consensus on proposed dosing for intravenous gentamicin in this population. METHODS The PubMed database was searched for articles published until the end of 2017. If the articles described population pharmacokinetic models of gentamicin in the paediatric population (after intravenous administration of gentamicin), the following data were extracted: type of study, year of publication, population characteristics and number of patients, gentamicin dosing, total number of gentamicin (serum and/or plasma) concentrations, type of population modelling approach, developed model with pharmacokinetic parameters and covariates included. RESULTS AND DISCUSSION In most of the studies, one- or two-compartment modelling was applied. The mean estimated gentamicin clearance for newborns, infants and the complete paediatric population was 0.048, 0.13 and 0.067 L/h/kg, respectively, and the mean predicted volume of distribution was 0.475, 0.35 and 0.33 L/kg, respectively. The values reflect differences in body composition and kidney maturation within the different paediatric populations. Gentamicin pharmacokinetics were most influenced by age, body size and renal function. WHAT IS NEW AND CONCLUSION Based on our review, the authors agree on a prolonged dosing interval for preterm and term newborns (up to 48 hours). However, there was no agreement on proposed dosing with respect to gestational age. In general, the proposed daily doses were lower compared to those initially applied for preterm newborns and comparable to those for term newborns. For infants and children, the dosing interval remained unchanged (24 hours), but the proposed daily doses were higher than actually applied. When differences in the paediatric population are considered and an appropriate population PK model with applicable covariates is applied, dosing can be individualized. In the future, studies of gentamicin pharmacokinetics in paediatric patients should focus on currently underestimated covariates, such as fat-free mass, concomitantly administered drugs, body temperature and critical illness because these can change gentamicin PK considerably. Consequently, different dosing is required and TDM becomes even more important.
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Affiliation(s)
- Mateja Crcek
- University of Ljubljana, Faculty of Pharmacy, Department of Biopharmaceutics and Pharmacokinetics, Ljubljana, Slovenia
| | - Jurij Zdovc
- University of Ljubljana, Faculty of Pharmacy, Department of Biopharmaceutics and Pharmacokinetics, Ljubljana, Slovenia
| | - Mojca Kerec Kos
- University of Ljubljana, Faculty of Pharmacy, Department of Biopharmaceutics and Pharmacokinetics, Ljubljana, Slovenia
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12
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McPherson C, Liviskie C, Zeller B, Nelson MP, Newland JG. Antimicrobial Stewardship in Neonates: Challenges and Opportunities. Neonatal Netw 2018; 37:116-123. [PMID: 29615159 DOI: 10.1891/0730-0832.37.2.116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neonatal infections result in significant morbidity and mortality. Antibiotics are vital for the treatment of infections but disrupt the neonatal microbiome, put the infant at risk for an adverse drug reaction, and may lead to the development of antibiotic resistance. Immediately after birth, clinicians must determine which infants require empiric antibiotics. Online risk stratification tools may provide a superior approach to decision trees. In infants who require empiric therapy for early-onset sepsis, ampicillin and an aminoglycoside with dosing based on recent pharmacokinetic studies represents the most appropriate first-line agents; third-generation cephalosporins should be reserved for patients with a high likelihood of Gram-negative meningitis. An antistaphylococcal penicillin and gentamicin should be utilized for suspected late-onset sepsis. Vancomycin and other broad-spectrum agents are reserved for patients with a history of resistant organisms. Antibiotic duration should be guided by understanding the clinical indications and obtaining the necessary cultures appropriately (i.e., adequate volume blood cultures). In the absence of a positive culture, antibiotic duration should often be limited. Individual institutions should leverage a multidisciplinary, interprofessional team to identify opportunities for antimicrobial stewardship. A collaborative, transparent system is required to change unit culture and generate a sustained impact on antibiotic utilization with optimal patient outcomes.
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13
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Fuchs A, Bielicki J, Mathur S, Sharland M, Van Den Anker JN. Reviewing the WHO guidelines for antibiotic use for sepsis in neonates and children. Paediatr Int Child Health 2018; 38:S3-S15. [PMID: 29790842 PMCID: PMC6176768 DOI: 10.1080/20469047.2017.1408738] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Guidelines from 2005 for treating suspected sepsis in low- and middle-income countries (LMIC) recommended hospitalisation and prophylactic intramuscular (IM) or intravenous (IV) ampicillin and gentamicin. In 2015, recommendations when referral to hospital is not possible suggest the administration of IM gentamicin and oral amoxicillin. In an era of increasing antimicrobial resistance, an updated review of the appropriate empirical therapy for treating sepsis (taking into account susceptibility patterns, cost and risk of adverse events) in neonates and children is necessary. Methods Systematic literature review and international guidelines were used to identify published evidence regarding the treatment of (suspected) sepsis. Results Five adequately designed and powered studies comparing antibiotic treatments in a low-risk community in neonates and young infants in LMIC were identified. These addressed potential simplifications of the current WHO treatment of reference, for infants for whom admission to inpatient care was not possible. Research is lacking regarding the treatment of suspected sepsis in neonates and children with hospital-acquired sepsis, despite rising antimicrobial resistance rates worldwide. Conclusions Current WHO guidelines supporting the use of gentamicin and penicillin for hospital-based patients or gentamicin (IM) and amoxicillin (oral) when referral to a hospital is not possible are in accordance with currently available evidence and other international guidelines, and there is no strong evidence to change this. The benefit of a cephalosporin alone or in combination as a second-line therapy in regions with known high rates of non-susceptibility is not well established. Further research into hospital-acquired sepsis in neonates and children is required.
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Affiliation(s)
- Aline Fuchs
- Paediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, Basel, Switzerland,Corresponding author.
| | - Julia Bielicki
- Paediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, Basel, Switzerland,Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
| | - Shrey Mathur
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
| | - Mike Sharland
- Paediatric Infectious Disease Research Group, Institute for Infection and Immunity, St George’s University of London, London, UK
| | - Johannes N. Van Den Anker
- Paediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, Basel, Switzerland,Division of Clinical Pharmacology, Children’s National Health System, Washington, DC, USA
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14
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van Donge T, Pfister M, Bielicki J, Csajka C, Rodieux F, van den Anker J, Fuchs A. Quantitative Analysis of Gentamicin Exposure in Neonates and Infants Calls into Question Its Current Dosing Recommendations. Antimicrob Agents Chemother 2018; 62:e02004-17. [PMID: 29358294 PMCID: PMC5913996 DOI: 10.1128/aac.02004-17] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/09/2018] [Indexed: 12/20/2022] Open
Abstract
Optimal dosing of gentamicin in neonates is still a matter of debate despite its common use. We identified gentamicin dosing regimens from eight international guidelines and seven Swiss neonatal intensive care units. The dose per administration, the dosing interval, the total daily dose, and the demographic characteristics between guidelines were compared. There was considerable variability with respect to dose (4 to 6 mg/kg), dosing interval (24 h to 48 h), total daily dose (2.5 to 6 mg/kg/day), and patient demographic characteristics that were used to calculate individualized dosing regimens. A model-based simulation study in 1071 neonates was performed to determine the achievement of efficacious peak gentamicin concentrations according to predefined MICs (Cmax/MIC ≥ 10) and safe trough concentrations (Cmin ≤ 2 mg/liter) with recommended dosing regimens. MIC targets of 0.5 and 1 mg/liter were used. Dosing optimization was performed giving priority to the first day of treatment and with the goal of simplifying dosing. Current gentamicin neonatal guidelines allow to achieve effective peak concentrations for MICs ≤ 0.5 mg/liter but not higher. Model-based simulations indicate that to attain peak gentamicin concentrations of ≥10 mg/liter, a dose of 7.5 mg/kg should be administered using an extended dosing interval regimen. Trough concentrations of ≤2 mg/liter can be maintained with a dosing interval of 36 to 48 h in neonates according to gestational and postnatal age. For treatment beyond 3 days, therapeutic drug monitoring is advised to maintain adequate serum concentrations.
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Affiliation(s)
- Tamara van Donge
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Pfister
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Quantitative Solutions, a Certara Company, London, United Kingdom
| | - Julia Bielicki
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, United Kingdom
| | - Chantal Csajka
- Service of Clinical Pharmacology, Department of Laboratory, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Frederique Rodieux
- Service of Clinical Pharmacology and Toxicology, Geneva University Hospitals, Geneva, Switzerland
| | - John van den Anker
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
- Intensive Care and Department of Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Aline Fuchs
- Paediatric Pharmacology and Pharmacometrics Research, University of Basel Children's Hospital, Basel, Switzerland
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15
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Rivera-Chaparro ND, Cohen-Wolkowiez M, Greenberg RG. Dosing antibiotics in neonates: review of the pharmacokinetic data. Future Microbiol 2017; 12:1001-1016. [PMID: 28758800 PMCID: PMC5627030 DOI: 10.2217/fmb-2017-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/23/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are often used in neonates despite the absence of relevant dosing information in drug labels. For neonatal dosing, clinicians must extrapolate data from studies for adults and older children, who have strikingly different physiologies. As a result, dosing extrapolation can lead to increased toxicity or efficacy failures in neonates. Driven by these differences and recent legislation mandating the study of drugs in children and neonates, an increasing number of pharmacokinetic studies of antibiotics are being performed in neonates. These studies have led to new dosing recommendations with particular consideration for neonate body size and maturation. Herein, we highlight the available pharmacokinetic data for commonly used systemic antibiotics in neonates.
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Affiliation(s)
- Nazario D Rivera-Chaparro
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
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