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Ashkenazi-Hoffnung L, Schiller O, Krubiner M, Dagan O, Haskin O, Manor-Shulman O, Feinstein Y, Shochat T, Shostak E, Yarden-Bilavsky H. Vancomycin Dosing and Its Association With Acute Kidney Injury in Pediatric Cardiac Intensive Care Patients Under 3 Months of Age. Pediatr Infect Dis J 2024; 43:963-969. [PMID: 38808996 DOI: 10.1097/inf.0000000000004415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
BACKGROUND The standard vancomycin regimen for term neonates is 45 mg/kg/day. However, the optimal starting vancomycin dosing for achieving therapeutic levels in young infants in cardiac intensive care units remains unknown. Moreover, data on the association of supratherapeutic vancomycin levels with acute kidney injury (AKI) are limited. METHODS Retrospective study of infants ≤3 months old, receiving vancomycin following congenital heart surgery at postoperative intensive care unit admission. Assessed were vancomycin dosing, achievement of therapeutic trough concentration of 10-20 mg/L and development of AKI, based on the modified Kidney Disease Improving Global Outcomes criteria. RESULTS Inclusion criteria were met by 109 patients with a median age of 8 days (IQR: 6-16). The mean (SD) vancomycin dose required for achieving therapeutic concentration was 28.9 (9.1) mg/kg at the first postoperative day. Multivariate logistic regression identified higher preoperative creatinine levels and shorter cardiopulmonary bypass time as predictors of supratherapeutic vancomycin concentrations (c-index 0.788). During the treatment course, 62 (56.9%) developed AKI. Length of stay and mortality were higher in those who developed AKI as compared with those who did not. Multivariate logistic regression identified higher vancomycin concentration as a predictor for postoperative AKI, OR, 3.391 (95% CI: 1.257-9.151), P = 0.016 (c-index 0.896). CONCLUSION Our results support a lower starting vancomycin dose of ~30 mg/kg/day followed by an early personalized therapeutic approach, to achieve therapeutic trough concentrations of 10-20 mg/L in cardiac postoperative term infants. Supratherapeutic concentrations are associated with an increased risk for AKI, which is prevalent in this population and associated with adverse outcomes.
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Affiliation(s)
- Liat Ashkenazi-Hoffnung
- From the Department of Day Hospitalization, Schneider Children's Medical Center, Petach Tikva, Israel
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Infectious Diseases Unit, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Ofer Schiller
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Mor Krubiner
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Ovadia Dagan
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Orly Haskin
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Institute of Nephrology, Schneider Children's Medical Center, Petach Tikva, Israel
| | - Orit Manor-Shulman
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yael Feinstein
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Tzippy Shochat
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Statistical Consultant, Clinical Research Authority, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
| | - Eran Shostak
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Havatzelet Yarden-Bilavsky
- Faculty of Medicine and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Pediatric Clinical Pharmacology Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
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Gérard R, Pauquet E, Ros B, Lehours P, Renesme L. Continuous Versus Intermittent Vancomycin Infusions for Coagulase-negative Staphylococcus Bacteremia in Neonates: A Propensity-matched Cohort Study. Pediatr Infect Dis J 2024:00006454-990000000-01000. [PMID: 39259856 DOI: 10.1097/inf.0000000000004538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
BACKGROUND Coagulase-negative staphylococci (CONS) are a major cause of late-onset neonatal sepsis, particularly in preterm infants, with high morbidity and mortality. While vancomycin is the first-line treatment for these infections, the optimal administration in neonates remains uncertain. OBJECTIVE We aim to compare the outcomes of neonates with CONS bacteremia treated with adjusted continuous infusion (CIV) versus standard intermittent infusion (IIV) of vancomycin. METHODS This retrospective study included 110 neonates, with 29 in the CIV group and 47 in the IIV group after propensity score matching. The primary outcome was treatment failure defined by the persistence of a positive blood culture for the same organism after at least 48 hours of vancomycin treatment. RESULTS After matching, the CIV group exhibited significantly lower treatment failure rates [5/29 (17%) vs. 26/47 (44%); P = 0.014] and a higher rate of achieving therapeutic vancomycin levels after 24 hours [20/29 (69%) vs. 26/47 (44%); P = 0.002] compared to the IIV group. No significant differences were observed in terms of acute kidney failure between the 2 groups. CONCLUSION Adjusted continuous vancomycin infusion in neonates with CONS bacteremia is associated with a lower treatment failure rate without an increase in renal toxicity compared to standard intermittent infusion. However, due to the observational design, larger prospective studies are needed to validate these results.
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Affiliation(s)
- Rémy Gérard
- From the Department of Pediatrics, Neonatal Intensive Care Unit
| | - Emilie Pauquet
- From the Department of Pediatrics, Neonatal Intensive Care Unit
| | - Barbara Ros
- Departement of Pediatrics, Neonatal and Pediatric Intensive Care Unit
| | - Philippe Lehours
- Microbiology Department, Bacteriology laboratory, University Hospital of Bordeaux
- Bordeaux Institute of Oncology, BRIC U1312, INSERM, University of Bordeaux, Bordeaux, France
| | - Laurent Renesme
- Department of Pediatrics, Neonatal Intensive Care Unit, Children's Hospital of Eastern Ontario, Ottawa, Canada
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Kontou A, Agakidou E, Chatziioannidis I, Chotas W, Thomaidou E, Sarafidis K. Antibiotics, Analgesic Sedatives, and Antiseizure Medications Frequently Used in Critically Ill Neonates: A Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2024; 11:871. [PMID: 39062320 PMCID: PMC11275925 DOI: 10.3390/children11070871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024]
Abstract
Antibiotic, analgesic sedative, and antiseizure medications are among the most commonly used medications in preterm/sick neonates, who are at high risk of nosocomial infections, central nervous system complications, and are exposed to numerous painful/stressful procedures. These severe and potentially life-threatening complications may have serious short- and long-term consequences and should be prevented and/or promptly treated. The reported variability in the medications used in neonates indicates the lack of adequate neonatal studies regarding their effectiveness and safety. Important obstacles contributing to inadequate studies in preterm/sick infants include difficulties in obtaining parental consent, physicians' unwillingness to recruit preterm infants, the off-label use of many medications in neonates, and other scientific and ethical concerns. This review is an update on the use of antimicrobials (antifungals), analgesics (sedatives), and antiseizure medications in neonates, focusing on current evidence or knowledge gaps regarding their pharmacokinetics, indications, safety, dosage, and evidence-based guidelines for their optimal use in neonates. We also address the effects of early antibiotic use on the intestinal microbiome and its association with long-term immune-related diseases, obesity, and neurodevelopment (ND). Recommendations for empirical treatment and the emergence of pathogen resistance to antimicrobials and antifungals are also presented. Finally, future perspectives on the prevention, modification, or reversal of antibiotic resistance are discussed.
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Affiliation(s)
- Angeliki Kontou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Eleni Agakidou
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - Ilias Chatziioannidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA
| | - Evanthia Thomaidou
- Department of Anesthesia and Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, AHEPA University General Hospital of Thessaloniki, 54621 Thessaloniki, Greece;
| | - Kosmas Sarafidis
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medicine, School of Health Sciences, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (I.C.); (K.S.)
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Blouin M, Métras MÉ, El Hassani M, Yaliniz A, Marsot A. Optimization of Vancomycin Initial Dosing Regimen in Neonates Using an Externally Evaluated Population Pharmacokinetic Model. Ther Drug Monit 2024:00007691-990000000-00235. [PMID: 38857472 DOI: 10.1097/ftd.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/27/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Vancomycin therapeutic monitoring guidelines were revised in March 2020, and a population pharmacokinetics-guided Bayesian approach to estimate the 24-hour area under the concentration-time curve to the minimum inhibitory concentration ratio has since been recommended instead of trough concentrations. To comply with these latest guidelines, we evaluated published population pharmacokinetic models of vancomycin using an external dataset of neonatal patients and selected the most predictive model to develop a new initial dosing regimen. METHODS The models were identified from the literature and tested using a retrospective dataset of Canadian neonates. Their predictive performance was assessed using prediction- and simulation-based diagnostics. Monte Carlo simulations were performed to develop the initial dosing regimen with the highest probability of therapeutic target attainment. RESULTS A total of 144 vancomycin concentrations were derived from 63 neonates in the external population. Five of the 28 models retained for evaluation were found predictive with a bias of 15% and an imprecision of 30%. Overall, the Grimsley and Thomson model performed best, with a bias of -0.8% and an imprecision of 20.9%; therefore, it was applied in the simulations. A novel initial dosing regimen of 15 mg/kg, followed by 11 mg/kg every 8 hours should favor therapeutic target attainment. CONCLUSIONS A predictive population pharmacokinetic model of vancomycin was identified after an external evaluation and used to recommend a novel initial dosing regimen. The implementation of these model-based tools may guide physicians in selecting the most appropriate initial vancomycin dose, leading to improved clinical outcomes.
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Affiliation(s)
- Mathieu Blouin
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Marie-Élaine Métras
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Department of Pharmacy, Centre Hospitalier Universitaire Sainte-Justine, Montréal (QC), Canada; and
| | - Mehdi El Hassani
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Aysenur Yaliniz
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
| | - Amélie Marsot
- STP Laboratory, Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Faculty of Pharmacy, Université de Montréal, Montréal (QC), Canada
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montréal (QC), Canada
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Kalamees R, Soeorg H, Ilmoja ML, Margus K, Lutsar I, Metsvaht T. Prospective validation of a model-informed precision dosing tool for vancomycin treatment in neonates. Antimicrob Agents Chemother 2024; 68:e0159123. [PMID: 38578080 PMCID: PMC11064528 DOI: 10.1128/aac.01591-23] [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: 12/12/2023] [Accepted: 03/13/2024] [Indexed: 04/06/2024] Open
Abstract
We recruited 48 neonates (50 vancomycin treatment episodes) in a prospective study to validate a model-informed precision dosing (MIPD) software. The initial vancomycin dose was based on a population pharmacokinetic model and adjusted every 36-48 h. Compared with a historical control group of 53 neonates (65 episodes), the achievement of a target trough concentration of 10-15 mg/L improved from 37% in the study to 62% in the MIPD group (P = 0.01), with no difference in side effects.
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Affiliation(s)
- Riste Kalamees
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Hiie Soeorg
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Mari-Liis Ilmoja
- Pediatric and Neonatal Intensive Care Unit, Tallinn Children’s Hospital, Tallinn, Estonia
| | - Kadri Margus
- Department of Neonatology, East Tallinn Central Hospital, Tallinn, Estonia
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Tuuli Metsvaht
- Department of Microbiology, University of Tartu, Tartu, Estonia
- Pediatric and Neonatal Intensive Care Unit, Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
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Alrahahleh D, Thoma Y, Van Daele R, Nguyen T, Halena S, Luig M, Stocker S, Kim HY, Alffenaar JW. Bayesian Vancomycin Model Selection for Therapeutic Drug Monitoring in Neonates. Clin Pharmacokinet 2024; 63:367-380. [PMID: 38416322 PMCID: PMC10954945 DOI: 10.1007/s40262-024-01353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND AND OBJECTIVE Pharmacokinetic models can inform drug dosing of vancomycin in neonates to optimize therapy. However, the model selected needs to describe the intended population to provide appropriate dose recommendations. Our study aims to identify the population pharmacokinetic (PopPK) model(s) with the best performance to predict vancomycin exposure in neonates in our hospital. METHODS Relevant published PopPK models for vancomycin in neonates were selected based on demographics and vancomycin dosing strategy. The predictive performance of the models was evaluated in Tucuxi using a local cohort of 69 neonates. Mean absolute error (MAE), relative bias (rBias) and relative root mean square error (rRMSE) were used to quantify the accuracy and precision of the predictive performance of each model for three different approaches: a priori, a posteriori, and Bayesian forecasting for the next course of therapy based on the previous course predictions. A PopPK model was considered clinically acceptable if rBias was between ± 20 and 95% confidence intervals included zero. RESULTS A total of 25 PopPK models were identified and nine were considered suitable for further evaluation. The model of De Cock et al. 2014 was the only clinically acceptable model based on a priori [MAE 0.35 mg/L, rBias 0.8 % (95% confidence interval (CI) - 7.5, 9.1%), and rRMSE 8.9%], a posteriori [MAE 0.037 mg/L, rBias - 0.23% (95% CI - 1.3, 0.88%), and rRMSE 6.02%] and Bayesian forecasting for the next courses [MAE 0.89 mg/L, rBias 5.45% (95% CI - 8.2, 19.1%), and rRMSE 38.3%) approaches. CONCLUSIONS The De Cock model was selected based on a comprehensive approach of model selection to individualize vancomycin dosing in our neonates.
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Affiliation(s)
- Dua'a Alrahahleh
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
| | - Yann Thoma
- School of Engineering and Management Vaud, HES-SO University of Applied Sciences and Arts Western Switzerland, 1400, Yverdon-les-Bains, Switzerland
| | - Ruth Van Daele
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
- Pharmacy Department, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Thi Nguyen
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
| | - Stephanie Halena
- Department of Pharmacy, Westmead Hospital, NSW, Westmead, Australia
| | - Melissa Luig
- Department of Neonatology, Westmead Hospital, Westmead, NSW, Australia
| | - Sophie Stocker
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- Westmead Hospital, Westmead, NSW, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital Sydney, Sydney, Australia
| | - Hannah Yejin Kim
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia
- Department of Pharmacy, Westmead Hospital, NSW, Westmead, Australia
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Pharmacy Building (A15), Camperdown, NSW, 2006, Australia.
- Westmead Hospital, Westmead, NSW, Australia.
- The University Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Westmead, NSW, Australia.
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7
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Chung E, Seto W. Using population pharmacokinetics to optimize initial vancomycin dosing guidelines for neonates to treat sepsis caused by coagulase-negative staphylococcus. Pharmacotherapy 2023; 43:1262-1276. [PMID: 37574774 DOI: 10.1002/phar.2865] [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: 03/17/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Vancomycin dosing tailored for newborns is challenging due to the significant influence of maturation and organ function on pharmacokinetics. Population pharmacokinetic (popPK) models can be used to improve target attainment in neonates. OBJECTIVES The primary objective was to derive and evaluate a popPK model of intravenous vancomycin for neonates. Second, the predictive performance of this popPK model was compared with published popPK models. METHODS This is a retrospective cohort study of neonates admitted to the neonatal intensive care unit receiving intravenous vancomycin. A popPK model was derived with 70% of the dataset using a nonlinear mixed effects modeling method. The predictive performance of the current popPK model was validated and compared with 22 published popPK models using the remaining 30% of the dataset. Monte Carlo simulations (MCS) were performed to derive optimal dosing regimens to treat neonatal sepsis caused by coagulase-negative staphylococci (CoNS). RESULTS Among 655 vancomycin courses from 448 neonates, 78% of vancomycin trough concentrations were outside target range (10-15 mg/L) for central nervous system infections and 43% were outside target range (5-12 mg/L) for other infections using the institution's vancomycin dosing. A one-compartment model best described the observed data with a mean clearance of 0.11 ± 0.03 L/kg/h and volume of distribution (V) of 1.02 ± 0.08 L/kg. Body weight (WT), postmenstrual age (PMA), and serum creatinine (SCr) were significant covariates associated with clearance (p < 0.001) and body WT was a significant covariate associated with V (p = 0.009). Our study's popPK model has similar or better accuracy and precision than other published models. MCS-derived vancomycin doses from the validated model achieved >90% target attainment for a steady state through target range of 10-15 mg/L in the majority of PMA and SCr categories (78%) to treat CoNS sepsis. CONCLUSION A vancomycin dosing guideline derived from a validated popPK model in neonates with CoNS sepsis is recommended to improve target attainment.
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Affiliation(s)
- Erin Chung
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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8
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Chung E, Seto W. Association between vancomycin therapeutic drug monitoring and clinical outcomes in treating neonatal sepsis. Int J Antimicrob Agents 2023; 62:106958. [PMID: 37633423 DOI: 10.1016/j.ijantimicag.2023.106958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Neonatal sepsis is commonly treated with vancomycin in the neonatal intensive care unit. Therapeutic drug monitoring of vancomycin is routinely used to personalise dosing to optimise effectiveness and avoid toxicity. OBJECTIVES This study aimed to define a target range by evaluating associations between vancomycin trough concentrations or area under the concentration time curve over 24 hours (AUC24h) and clinical outcomes in neonates. METHODS Neonates, who were admitted to the neonatal intensive care unit and received intravenous vancomycin, were included in this retrospective cohort study. For evaluating effectiveness, patients who received vancomycin for < 5 days were excluded. The AUC24h was estimated based on a study-derived population pharmacokinetic model. Primary outcomes were persistent/recurrent infections and mortality within 30 days. Secondary outcomes, including acute kidney injury (AKI), were also assessed. Logistic regression and classification and regression tree analyses were performed. RESULTS A total of 448 patients (123 patients for effectiveness analysis) were included. A vancomycin trough > 10 mg/L was associated with 70% lower odds of persistent/recurrent infections (adjusted OR 0.30, 95% CI 0.09-0.86; P = 0.023). Patients who took more than a day to reach target range had 1.4 times higher odds of persistent/recurrent infections or death (P = 0.04). A vancomycin trough > 15 mg/L was associated with a three times higher risk of AKI (P = 0.003). An AUC24h of 420-650 mg*h/L was also associated with the lowest risk of composite outcomes (adjusted OR 0.29, 95% CI 0.08-0.86; P = 0.025). CONCLUSION A vancomycin trough target range of 10-15 mg/L and achievement of this target within a day of treatment initiation were associated with the most optimal clinical outcomes in treating neonatal sepsis.
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Affiliation(s)
- Erin Chung
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
| | - Winnie Seto
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto Ontario, Canada
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9
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Tang BH, Zhang JY, Allegaert K, Hao GX, Yao BF, Leroux S, Thomson AH, Yu Z, Gao F, Zheng Y, Zhou Y, Capparelli EV, Biran V, Simon N, Meibohm B, Lo YL, Marques R, Peris JE, Lutsar I, Saito J, Jacqz-Aigrain E, van den Anker J, Wu YE, Zhao W. Use of Machine Learning for Dosage Individualization of Vancomycin in Neonates. Clin Pharmacokinet 2023; 62:1105-1116. [PMID: 37300630 DOI: 10.1007/s40262-023-01265-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE High variability in vancomycin exposure in neonates requires advanced individualized dosing regimens. Achieving steady-state trough concentration (C0) and steady-state area-under-curve (AUC0-24) targets is important to optimize treatment. The objective was to evaluate whether machine learning (ML) can be used to predict these treatment targets to calculate optimal individual dosing regimens under intermittent administration conditions. METHODS C0 were retrieved from a large neonatal vancomycin dataset. Individual estimates of AUC0-24 were obtained from Bayesian post hoc estimation. Various ML algorithms were used for model building to C0 and AUC0-24. An external dataset was used for predictive performance evaluation. RESULTS Before starting treatment, C0 can be predicted a priori using the Catboost-based C0-ML model combined with dosing regimen and nine covariates. External validation results showed a 42.5% improvement in prediction accuracy by using the ML model compared with the population pharmacokinetic model. The virtual trial showed that using the ML optimized dose; 80.3% of the virtual neonates achieved the pharmacodynamic target (C0 in the range of 10-20 mg/L), much higher than the international standard dose (37.7-61.5%). Once therapeutic drug monitoring (TDM) measurements (C0) in patients have been obtained, AUC0-24 can be further predicted using the Catboost-based AUC-ML model combined with C0 and nine covariates. External validation results showed that the AUC-ML model can achieve an prediction accuracy of 80.3%. CONCLUSION C0-based and AUC0-24-based ML models were developed accurately and precisely. These can be used for individual dose recommendations of vancomycin in neonates before treatment and dose revision after the first TDM result is obtained, respectively.
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Affiliation(s)
- Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | | | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, the Netherlands
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | | | - Alison H Thomson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Ze Yu
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Fei Gao
- Beijing Medicinovo Technology Co. Ltd., Beijing, China
| | - Yi Zheng
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Edmund V Capparelli
- Pediatric Pharmacology and Drug Discovery, University of California, San Diego, CA, USA
| | - Valerie Biran
- Neonatal Intensive Care Unit, Hospital Robert Debre, Paris, France
| | - Nicolas Simon
- Service de Pharmacologie Clinique, CAP-TV, Aix Marseille Univ, APHM, INSERM, IRD, SESSTIM, Hop Sainte Marguerite, Marseille, France
| | - Bernd Meibohm
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Yoke-Lin Lo
- Department of Pharmacy, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
| | - Remedios Marques
- Department of Pharmacy Services, La Fe Hospital, Valencia, Spain
| | - Jose-Esteban Peris
- Department of Pharmacy and Pharmaceutical Technology, University of Valencia, Valencia, Spain
| | - Irja Lutsar
- Institute of Medical Microbiology, University of Tartu, Tartu, Estonia
| | - Jumpei Saito
- Department of Pharmacy, National Children's Hospital National Center for Child Health and Development, Tokyo, Japan
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hospital Robert Debre, APHP, Paris, France
- Clinical Investigation Center CIC1426, Hôpital Robert Debré, Paris, France
- University Paris Diderot, Sorbonne Paris Cite, Paris, France
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, Pharmacology and Physiology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Genomics and Precision Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Department of Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.
- NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, Qilu Hospital of Shandong University, Shandong University, Jinan, China.
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10
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Aljutayli A, Thirion DJ, Nekka F. Critical assessment of the revised guidelines for vancomycin therapeutic drug monitoring. Biomed Pharmacother 2022; 155:113777. [DOI: 10.1016/j.biopha.2022.113777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/02/2022] Open
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11
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Lee TY, Hung YL, Shen CM, Kao CL, Hsieh WS. Reappraisal of therapeutic vancomycin trough concentrations with empirical dosing in neonatal infections. Pediatr Neonatol 2022; 64:176-182. [PMID: 36344414 DOI: 10.1016/j.pedneo.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 04/06/2022] [Accepted: 05/17/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Vancomycin is commonly used for neonatal sepsis. However, consensus on an empirical neonatal vancomycin regimen remains uncertain. We aimed to reappraise the therapeutic optimum concerning vancomycin trough concentrations with empirical dosing and to evaluate the relationship between trough concentrations and predicted 24-h area under the curve (AUC24). METHODS This was a 3-year retrospective study. Neonates who were admitted to the neonatal intensive care unit with available vancomycin trough concentrations were enrolled. Trough levels were obtained before the fourth dose. Achievement of goal trough after implementing the vancomycin dosing regimen was based on the Practical Neonatology Medical Manual, published by the National Taiwan University College of Medicine. RESULTS A total of 46 neonates were included for analysis. Coagulase-negative staphylococci were the most commonly identified pathogens of sepsis. Among these patients, 22 achieved goal trough levels of 10-20 mcg/mL. Trough levels of 5-10 or >20 mcg/mL occurred in 13 and 11 patients, respectively. A moderately positive correlation between trough and predicted AUC24 was found in all patients (Spearman's rho = 0.676, p < 0.001). In patients with body weight 1200-2000 g and postnatal age >7 days, the serum creatinine of those with trough levels >20 mcg/mL was significantly higher than those with goal trough levels (0.61 vs. 0.45 mg/dL, p = 0.01). Among those with trough levels >20 mcg/mL, 5 patients received ibuprofen for patent ductus arteriosus closing prior to vancomycin treatment (45%, 5/11), compared to only 3 patients with trough levels <20 mcg/mL (9%, 3/35) (p = 0.013). CONCLUSION Only half of the neonates receiving empirical vancomycin regimen achieved goal trough levels of 10-20 mcg/mL. Higher serum creatinine or ibuprofen treatment may increase the risk of overly high trough levels. The vancomycin regimen needs further validation and modification to provide adequate dosing for optimal use in neonates.
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Affiliation(s)
- Tzung-Yi Lee
- Department of Pharmacy, Cathay General Hospital, Taipei, Taiwan
| | - Yi-Li Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chung-Min Shen
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chi-Lan Kao
- Department of Pharmacy, Cathay General Hospital, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University College of Medicine, Taipei, Taiwan.
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12
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External Validation of a Vancomycin Population Pharmacokinetic Model and Developing a New Dosage Regimen in Neonates. Eur J Drug Metab Pharmacokinet 2022; 47:687-697. [PMID: 35804218 DOI: 10.1007/s13318-022-00781-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Vancomycin is the drug of choice in the treatment of MRSA infections. In a published vancomycin population pharmacokinetic study on neonates in Singapore healthcare institutions, it was found that vancomycin clearance was predicted by weight, postmenstrual age, and serum creatinine. The aim of this study was to externally validate the vancomycin population pharmacokinetic model to develop a new dosage regimen in neonates, and to compare this regimen with the existing institutional and NeoFax® dosage regimens. METHODS A retrospective chart review of neonates who received vancomycin therapy and therapeutic drug monitoring was conducted. The median prediction error percentage was calculated to assess bias, while the median absolute prediction error percentage and the root mean squared error percentage were calculated to assess precision. The new dosage regimen was developed using Monte Carlo simulation. RESULTS A total of 20 neonates were included in the external validation dataset. Eighteen of them were premature, with a median gestational age of 27.7 (25.9-31.5) weeks and postmenstrual age of 30.5 (27.3-34.3) weeks at the point of vancomycin initiation. No apparent systematic bias was found in the predictions of the model. The external validation performed in the current study found the model to be generally unbiased. Our new vancomycin dosage regimen was able to achieve target trough concentrations and area under the curve (AUC24) at a greater proportion as compared to existing institutional and NeoFax® dosage regimens. CONCLUSION The pharmacokinetic model built in the previous study can be used to conduct reliable population simulations of our Asian neonatal population in Singapore. The new dosage regimen was able to achieve target trough concentrations and AUC24 better than existing institutional and NeoFax® dosage regimens.
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13
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Implementation of a Vancomycin Dose-Optimization Protocol in Neonates: Impact on Vancomycin Exposure, Biological Parameters, and Clinical Outcomes. Antimicrob Agents Chemother 2022; 66:e0219121. [PMID: 35465728 DOI: 10.1128/aac.02191-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Vancomycin dosing used in neonates results frequently in insufficient concentrations. A vancomycin dose-optimization protocol consisting of an individualization of loading and maintenance doses (administered during continuous infusion) through a previously validated pharmacokinetic model was implemented in our center. This monocenter retrospective study aimed to compare vancomycin average concentration (Cavg) in the therapeutic range (15 to 25 mg/L) and biological and clinical parameters before and after implementation of this protocol. A total of 60 and 59 courses of vancomycin treatment in 45 and 49 patients were analyzed in groups before and after implementation, respectively. Initial vancomycin Cavg were more frequently in the therapeutic range in the group after implementation (74.6% versus 28.3%, P < 0.001), with 1.6-fold higher Cavg (20.3 [17.0-22.2] mg/L versus 12.9 [11.3-17.0] mg/L, P < 0.001). Considering all Cavg during longitudinal therapeutic drug monitoring (TDM), the frequency of therapeutic Cavg was higher in the group after implementation (74.8% [n = 103] versus 31% [n = 116], P < 0.001). The dose optimization protocol was also associated with a reduced time to obtain a negative blood culture (P < 0.001) and fewer antibiotic switches (P = 0.025), without increasing the frequency of nephrotoxicity. Clinical outcomes also appeared to be improved, with less periventricular leukomalacia (P = 0.021), trended toward less respiratory instability (P = 0.15) and a shorter duration of vasoactive drug use (P = 0.18) for neonates receiving personalized doses of vancomycin. This personalized vancomycin dose protocol improves vancomycin exposure in neonates, with good safety, and suggests an improvement in biological and clinical outcomes.
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14
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Evaluation of Therapeutic Vancomycin Monitoring in Taiwan. Microbiol Spectr 2022; 10:e0156221. [PMID: 35412391 PMCID: PMC9045330 DOI: 10.1128/spectrum.01562-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study aimed to evaluate whether trough level-guided monitoring can be replaced by area under the concentration–time curve (AUC) and MIC ratio-guided monitoring (AUC/MIC ratio = 400) in patients infected with methicillin-resistant Staphylococcus aureus (MRSA) with a vancomycin MIC = 1 mg/L in Taiwan. In this retrospective study, patients treated with vancomycin for Methicillin-resistant Staphylococcus aureus (MRSA) infection were recruited from a teaching hospital in Taiwan from January 2016 to December 2017. Average trough concentrations were adjusted based on the average daily vancomycin dose, and the AUC/MIC ratio was calculated using the AUC/MIC conversion formula to analyze the correlation between trough or AUC/MIC ratio, nephrotoxicity, and clinical efficacy. As the primary outcome, the overall mean adjusted vancomycin average AUC/MIC ratio was 526.87 for a total of 102 patients. A total of 67% and 76% of the patients attained an AUC/MIC of ≥400 when the adjusted vancomycin trough concentrations were 10 to 15 mg/L and 15 to 20 mg/L, respectively. Additionally, 81.37% of the total study population had MRSA isolates with a vancomycin MIC of ≤1 mg/L. Moreover, in the subgroup, 92% of the patients attained an AUC/MIC of ≥400 on receiving vancomycin in the 10 to 15 mg/L trough range. An AUC/MIC of ≥400 was attained in patients infected with MRSA strains, who were treated by maintaining the vancomycin trough concentrations at 10 to 15 mg/L. Moreover, these patients demonstrated a lower incidence of nephrotoxicity. These findings support the use of the AUC/MIC ratio as a useful marker for the therapeutic monitoring of vancomycin owing to the clinical efficacy and safety of vancomycin in Taiwan. IMPORTANCE Since 2020, the Infectious Diseases Society of America (IDSA) updated vancomycin guidelines, and vancomycin AUC therapeutic drug monitor was updated to AUC/MIC in the United States. But acceptable rate of infection physicians in Taiwan was low. That is why this study evaluated in Taiwan.
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15
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AbuSara AK, Abdelrahman DH, Habash KI, Al-Shaer MH, Le J, Nazer LH. Vancomycin therapeutic monitoring by measured trough concentration versus Bayesian-derived area under the curve in critically ill patients with cancer. Pharmacol Res Perspect 2022; 10:e00912. [PMID: 34990089 PMCID: PMC8929348 DOI: 10.1002/prp2.912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Abstract
The updated vancomycin guideline and recent studies suggested that trough concentrations may result in underestimation of the actual area under the curve (AUC), leading to excessive dosing and nephrotoxicity. With limited data available on critically ill cancer patients, this study aimed to compare the two methods in this patient population. This was a 5‐year retrospective study on patients treated with vancomycin in the intensive care unit (ICU) of a comprehensive cancer center. The measured trough concentration was compared to Bayesian‐derived AUC/minimum‐inhibitory‐concentration (MIC), considering MIC as 1. Trough concentrations of 15–20 mg/L and AUC of 400–600 mg h/L were considered the targeted goal. Multivariate analysis was performed to identify factors associated with an AUC below the targeted goal. During the study period, 316 patients were included. The mean age was 54 years ±16 (SD); most patients had solid tumors (75%), and 11% had neutropenia. A targeted goal AUC and trough were recorded in 128 (41%) patients and in 64 (20%) patients, respectively. Of the 128 patients with targeted goal AUC, 31 (24%) had targeted goal trough concentrations and 91 (71%) had trough concentrations below 15 mg/L. Furthermore, among the patients with targeted goal trough concentration (n = 64), 33 (52%) had higher than targeted goal AUC. Augmented renal clearance (ARC), defined as a calculated creatinine‐clearance ≥130 ml/min, was associated with an AUC below the targeted goal. In a cohort of critically ill patients with cancer, over two‐thirds of the patients with a targeted goal Bayesian AUC/MIC had trough concentrations below the targeted goal. ARC was associated with AUC below the targeted goal.
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Affiliation(s)
- Aseel K AbuSara
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | | | - Khader I Habash
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
| | - Mohammad H Al-Shaer
- Infectious Disease Pharmacokinetics Laboratory, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, La Jolla, California, USA
| | - Lama H Nazer
- Department of Pharmacy, King Hussein Cancer Center, Amman, Jordan
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16
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Dilworth TJ, Schulz LT, Rose WE. Vancomycin Advanced Therapeutic Drug Monitoring: Exercise in Futility or Virtuous Endeavor to Improve Drug Efficacy and Safety? Clin Infect Dis 2021; 72:e675-e681. [PMID: 32898221 DOI: 10.1093/cid/ciaa1354] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022] Open
Abstract
Vancomycin is commonly prescribed to hospitalized patients. Decades of pharmacokinetic/pharmacodynamic research culminated in recommendations to monitor the ratio of the area under the concentration-time curve (AUC) to the minimum inhibitory concentration in order to optimize vancomycin exposure and minimize toxicity in the revised 2020 guidelines. These guideline recommendations are based on limited data without high-quality evidence and limitations in strength. Despite considerable effort placed on vancomycin therapeutic drug monitoring (TDM), clinicians should recognize that the majority of vancomycin use is empiric. Most patients prescribed empiric vancomycin do not require it beyond a few days. For these patients, AUC determinations during the initial days of vancomycin exposure are futile. This added workload may detract from high-level patient care activities. Loading doses likely achieve AUC targets, so AUC monitoring after a loading dose is largely unnecessary for broad application. The excessive vancomycin TDM for decades has been propagated with limitations in evidence, and it should raise caution on contemporary vancomycin TDM recommendations.
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Affiliation(s)
| | | | - Warren E Rose
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, USA
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17
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Jorgensen SCJ, Spellberg B, Shorr AF, Wright WF. Should Therapeutic Drug Monitoring Based on the Vancomycin Area Under the Concentration-Time Curve Be Standard for Serious Methicillin-Resistant Staphylococcus aureus Infections?-No. Clin Infect Dis 2021; 72:1502-1506. [PMID: 33740050 DOI: 10.1093/cid/ciaa1743] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Indexed: 12/16/2022] Open
Abstract
In this counterpoint we critically appraise the evidence supporting therapeutic drug monitoring based on the vancomycin 24-hour area under the concentration-time curve (AUC24) for serious methicillin-resistant Staphylococcus aureus infections. We reveal methodologically weaknesses and inconsistencies in the data and suggest that, in the absence of clear and convincing evidence of benefit compared with modestly reducing trough targets, alternative strategies are more likely to result in superior safety and efficacy. These include focusing on fundamental antibiotic stewardship to limit vancomycin exposure overall, achieving earlier and more complete source control, and establishing alternative therapeutic options to vancomycin. Implementation of AUC24-based therapeutic drug monitoring will take resources away from these more promising, alternative solutions.
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Affiliation(s)
| | - Brad Spellberg
- Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, California, USA
| | - Andrew F Shorr
- Division of Pulmonary and Critical Care, Department of Medicine, Washington Hospital Center, Washington, DC, USA
| | - William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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18
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Wright WF, Jorgensen SCJ, Spellberg B. Heaping the Pelion of Vancomycin on the Ossa of Methicillin-resistant Staphylococcus aureus: Back to Basics in Clinical Care and Guidelines. Clin Infect Dis 2021; 72:e682-e684. [PMID: 32901250 PMCID: PMC8130018 DOI: 10.1093/cid/ciaa1360] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- William F Wright
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Brad Spellberg
- Los Angeles County + University of Southern California Medical Center, Los Angeles, California, USA
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19
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Population Pharmacokinetic Models of Vancomycin in Paediatric Patients: A Systematic Review. Clin Pharmacokinet 2021; 60:985-1001. [PMID: 34002357 DOI: 10.1007/s40262-021-01027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Vancomycin is commonly used to treat gram-positive bacterial infections in the paediatric population, but dosing can be challenging. Population pharmacokinetic (popPK) modelling can improve individualization of dosing regimens. The primary objective of this study was to describe popPK models of vancomycin and factors that influence pharmacokinetic (PK) variability in paediatric patients. METHODS Systematic searches were conducted in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, International Pharmaceutical Abstracts and the grey literature without language or publication status restrictions from inception to 17 August 2020. Observational studies that described the development of popPK models of vancomycin in paediatric patients (< 18 years of age) were included. Risk of bias was assessed using the National Heart, Lung and Blood Institute Study Quality Assessment Tool for Case Series Studies. RESULTS Sixty-four observational studies (1 randomized controlled trial, 13 prospective studies and 50 retrospective studies of 9019 patients with at least 25,769 serum vancomycin concentrations) were included. The mean age was 2.5 years (range 1 day-18 years), serum creatinine was 47.1 ± 33.6 µmol/L, and estimated creatinine clearance was 97.4 ± 76 mL/min/1.73m2. Most studies found that vancomycin PK was best described by a one-compartment model (71.9%). There was a wide range of clearance and volume of distribution (Vd) values (range 0.014-0.27 L/kg/h and 0.43-1.46 L/kg, respectively) with interindividual variability as high as 49.7% for clearance and 136% for Vd, proportional residual variability up to 37.5% and additive residual variability up to 17.5 mg/L. The most significant covariates for clearance were weight, age, and serum creatinine or creatinine clearance, and weight for Vd. Variable dosing recommendations were suggested. CONCLUSION Numerous popPK models of vancomycin were derived, however external validation of suggested dosing regimens and analyses in subgroup paediatric populations such as dialysis patients are still needed before a popPK model with best predictive performance can be applied for dosing recommendations. Significant intraindividual and interindividual PK variability was present, which demonstrated the need for ongoing therapeutic drug monitoring and derivation of PK models for vancomycin for certain subgroup populations, such as dialysis patients.
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20
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Mejías-Trueba M, Alonso-Moreno M, Herrera-Hidalgo L, Gil-Navarro MV. Target Attainment and Clinical Efficacy for Vancomycin in Neonates: Systematic Review. Antibiotics (Basel) 2021; 10:347. [PMID: 33805874 PMCID: PMC8064372 DOI: 10.3390/antibiotics10040347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/14/2021] [Accepted: 03/21/2021] [Indexed: 01/22/2023] Open
Abstract
Vancomycin is commonly used as a treatment for neonatal infections. However, there is a lack of consensus establishing the optimal vancomycin therapeutic regimen and defining the most appropriate PK/PD parameter correlated with the efficacy. A recent guideline recommends AUC-guided therapeutic dosing in treating serious infections in neonates. However, in clinical practice, trough serum concentrations are commonly used as a surrogate PKPD index for AUC24. Despite this, target serum concentrations in a neonatal population remain poorly defined. The objective is to describe the relationship between therapeutic regimens and the achievement of clinical or pharmacokinetic outcomes in the neonatal population. The review was carried out following PRISMA guidelines. A bibliographic search was manually performed for studies published on PubMed and EMBASE. Clinical efficacy and/or target attainment and the safety of vancomycin treatment were evaluated through obtaining serum concentrations. A total of 476 articles were identified, of which 20 met the inclusion criteria. All of them evaluated the target attainment, but only two assessed the clinical efficacy. The enormous variability concerning target serum concentrations is noteworthy, which translates into a difficulty in determining which therapeutic regimen achieves the best results. Moreover, there are few studies that analyze clinical efficacy results obtained after reaching predefined trough serum concentrations, this information being essential for clinical practice.
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Affiliation(s)
- Marta Mejías-Trueba
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.M.-T.); (M.A.-M.)
| | - Marta Alonso-Moreno
- Unidad de Gestión Clínica de Farmacia, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (M.M.-T.); (M.A.-M.)
| | - Laura Herrera-Hidalgo
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
| | - Maria Victoria Gil-Navarro
- Unidad de Gestión Clínica de Farmacia, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, 41013 Seville, Spain;
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21
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Lee SM, Yang S, Kang S, Chang MJ. Population pharmacokinetics and dose optimization of vancomycin in neonates. Sci Rep 2021; 11:6168. [PMID: 33731764 PMCID: PMC7969932 DOI: 10.1038/s41598-021-85529-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 02/26/2021] [Indexed: 01/12/2023] Open
Abstract
The pharmacokinetics of vancomycin vary among neonates, and we aimed to conduct population pharmacokinetic analysis to determine the optimal dosage of vancomycin in Korean neonates. From a retrospective chart review, neonates treated with vancomycin from 2008 to 2017 in a neonatal intensive care unit (NICU) were included. Vancomycin concentrations were collected based on therapeutic drug monitoring, and other patient characteristics were gathered through electronic medical records. We applied nonlinear mixed-effect modeling to build the population pharmacokinetic model. One- and two-compartment models with first-order elimination were evaluated as potential structural pharmacokinetic models. Allometric and isometric scaling was applied to standardize pharmacokinetic parameters for clearance and volume of distribution, respectively, using fixed powers (0.75 and 1, respectively, for clearance and volume). The predictive performance of the final model was developed, and dosing strategies were explored using Monte Carlo simulations with AUC0–24 targets 400–600. The patient cohort included 207 neonates, and 900 vancomycin concentrations were analyzed. Only 37.4% of the analyzed concentrations were within trough concentrations 5–15 µg/mL. A one-compartment model with first-order elimination best described the vancomycin pharmacokinetics in neonates. Postmenstrual age (PMA) and creatinine clearance (CLcr) affected the clearance of vancomycin, and model evaluation confirmed the robustness of the final model. Population pharmacokinetic modeling and dose optimization of vancomycin in Korean neonates showed that vancomycin clearance was related to PMA and CLcr, as well as body weight. A higher dosage regimen than the typical recommendation is suggested.
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Affiliation(s)
- Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Seungwon Yang
- Department of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Soyoung Kang
- Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Veritas Hall D #214, Yonsei University International Campus, Songdogwahak-ro 85, Yeonsu-gu, Incheon, Korea
| | - Min Jung Chang
- Department of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea. .,Department of Pharmaceutical Medicine and Regulatory Science, Yonsei University, Veritas Hall D #214, Yonsei University International Campus, Songdogwahak-ro 85, Yeonsu-gu, Incheon, Korea.
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22
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Jorgensen SCJ, Dersch-Mills D, Timberlake K, Stewart JJ, Gin A, Dresser LD, Dalton BR. AUCs and 123s: a critical appraisal of vancomycin therapeutic drug monitoring in paediatrics. J Antimicrob Chemother 2021; 76:2237-2251. [PMID: 33675656 DOI: 10.1093/jac/dkab048] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The revised vancomycin guidelines recommend implementing AUC24-based therapeutic drug monitoring (TDM) using Bayesian methods in both adults and paediatrics. The motivation for this change was accumulating evidence showing aggressive dosing to achieve high troughs, as recommended in the first guidelines for adults and extrapolated to paediatrics, is associated with increased nephrotoxicity without improving clinical outcomes. AUC24-based TDM requires substantial resources that may need to be diverted from other valuable interventions. It can therefore be justified only after certain assumptions are shown to be true: (i) there is a clear relationship between vancomycin efficacy and/or toxicity and the proposed therapeutic range; and (ii) maintaining exposure within the target range with AUC24-based TDM improves clinical outcomes and/or decreases toxicity. In this review, we critically appraise the scientific basis for these assumptions. We find studies evaluating the relationship between vancomycin AUC24/MIC and efficacy in adults and children do not offer strong support for the recommended lower limit of the proposed therapeutic range (i.e. AUC24/MIC ≥400). Nephrotoxicity in children increases in a stepwise manner along the vancomycin exposure continuum but it is unclear if one parameter (AUC24 versus trough) is a superior predictor. Overall, evidence in children suggests good-to-excellent correlation between AUC24 and trough. Most importantly, there is no convincing evidence that the method of vancomycin TDM has a causal role in improving efficacy or reducing toxicity. These findings question the need to transition to resource-intensive AUC24-based TDM over retaining trough-based TDM with lower targets to minimize nephrotoxicity in paediatrics.
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Affiliation(s)
| | | | - Kathryn Timberlake
- Department of Pharmacy, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jackson J Stewart
- Pharmacy Services, University of Alberta Hospital, Edmonton, AB, Canada
| | - Alfred Gin
- Department of Pharmacy, Winnipeg Regional Health Authority, Winnipeg, MB, Canada.,Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Linda D Dresser
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Antimicrobial Stewardship Program, University Health Network, Toronto, ON, Canada
| | - Bruce R Dalton
- Pharmacy Services, Alberta Health Services, Calgary, AB, Canada
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23
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Population Pharmacokinetic Analysis and Dose Regimen Optimization in Japanese Infants with an Extremely Low Birth Weight. Antimicrob Agents Chemother 2021; 65:AAC.02523-20. [PMID: 33318009 DOI: 10.1128/aac.02523-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/04/2020] [Indexed: 12/17/2022] Open
Abstract
Vancomycin is a synthetic antibiotic effective against Gram-positive pathogens. Although the clinical applicability of vancomycin for infants has been increasing, the pharmacokinetic data for vancomycin in extremely low-birth-weight infants are limited. The aim of this study was to construct a population pharmacokinetics model for vancomycin in extremely-low-birth-weight infants and establish an optimal dosage regimen. We enrolled children aged less than 1 year with a birth weight of less than 1,000 g and body weight at vancomycin prescription of less than 1,500 g. Pharmacokinetic data from 19 patients were analyzed, and a population pharmacokinetics model was developed using nonlinear mixed-effects modeling software. Goodness-of-fit plots, a nonparametric bootstrap analysis, and a prediction-corrected visual predictive check were employed to evaluate the final model. The dosage regimen was optimized based on the final model. The pharmacokinetic data fit a one-compartment model with first-order elimination, and body weight and estimated serum creatinine level were used as significant covariates. In a simulation using the final model, the optimal dosage regimen, especially when the serum creatinine level (>0.6 mg/dl) was high, was 5.0 to 7.5 mg/kg of body weight twice a day every 12 h; this was required to reduce the dosage compared with that in previous studies. The recommended doses based on the current target time course concentration curves may not be appropriate for extremely-low-birth-weight infants.
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Burns AN, Goldman JL. A Moving Target-Vancomycin Therapeutic Monitoring. J Pediatric Infect Dis Soc 2020; 9:474-478. [PMID: 32716487 DOI: 10.1093/jpids/piaa078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 11/13/2022]
Abstract
Therapeutic drug monitoring (TDM) has been a common practice to optimize efficacy and safety of vancomycin. While vancomycin trough-only TDM has widely been integrated into pediatric clinical practice since 2009, recently updated vancomycin TDM guidelines published in March 2020 recommend area under the curve (AUC) based TDM for vancomycin instead of trough-only TDM. In this review, we discuss the rationale behind the change in TDM recommendations, describe two approaches for calculating vancomycin AUC in clinical practice, and address considerations for integrating vancomycin AUC TDM into pediatric clinical practice. Our primary goal is to provide pediatric clinicians with a resource for implementing vancomycin AUC monitoring into clinical care.
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Affiliation(s)
- Alaina N Burns
- Department of Pharmacy, Children's Mercy Hospital, Kansas City, Missouri, USA.,Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jennifer L Goldman
- Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
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Shin S, Jung HJ, Jeon SM, Park YJ, Chae JW, Yun HY. Vancomycin Dosage and Its Association with Clinical Outcomes in Pediatric Patients with Gram-Positive Bacterial Infections. Risk Manag Healthc Policy 2020; 13:685-695. [PMID: 32636687 PMCID: PMC7334008 DOI: 10.2147/rmhp.s244836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 05/07/2020] [Indexed: 11/23/2022] Open
Abstract
Aim The aim of this study was to evaluate whether vancomycin trough concentrations at initial steady state are associated with clinical and microbiological outcomes along with vancomycin-related nephrotoxicity in pediatric patients with Gram-positive bacterial (GPB) infections. Methods A retrospective cohort study of pediatric patients who received vancomycin for ≥72 hours during 2008–2016 was conducted. Study patients were divided into three cohorts in accordance with their first trough levels at steady state: <5 mg/L (lower-trough), 5–10 mg/L (low-trough), and >10 mg/L (high-trough; reference) cohorts. Results Of the 201 patients eligible for study inclusion, 60 patients in the lower- and low-trough cohorts, respectively, were idect 3ntified via propensity score matching and analyzed against 30 high-trough patients in each comparison pair (neonates were excluded due to small sample size). Lower-trough patients were at a greater risk for prolonged therapy, retreatment, and dose adjustment than high-trough patients. Final steady-state troughs remained substantially lower in both the lower- and low-trough cohorts (p<0.001 and p=0.005, respectively), despite greater dose up-titration in the lower-trough cohort and percent change in daily dose in both the lower- and low-trough cohorts than in the high-trough cohort (p<0.001 for all). Clinical cure and death risk, along with the risks of isolation of resistant strains and renal events, were not significantly different between cohorts in both comparison pairs. Conclusion Vancomycin troughs of <5 mg/L at initial steady state were associated with significantly compromised clinical outcomes in terms of risk of therapy prolongation, retreatment, and aggressive dose up-titration, compared to >10 mg/L troughs in pediatric patients with GPB infections.
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Affiliation(s)
- Sooyoung Shin
- College of Pharmacy, Ajou University, Suwon, Gyeonggi-do 16499, Republic of Korea.,College of Pharmacy, Chungnam National University, Daejeon 34134, Republic of Korea
| | - Hyun Joo Jung
- Department of Pediatrics, Ajou University Hospital, Suwon, Gyeonggi-do 16499, Republic of Korea
| | - Sang-Min Jeon
- College of Pharmacy, Ajou University, Suwon, Gyeonggi-do 16499, Republic of Korea
| | - Young-Joon Park
- College of Pharmacy, Ajou University, Suwon, Gyeonggi-do 16499, Republic of Korea
| | - Jung-Woo Chae
- College of Pharmacy, Chungnam National University, Daejeon 34134, Republic of Korea
| | - Hwi-Yeol Yun
- College of Pharmacy, Chungnam National University, Daejeon 34134, Republic of Korea
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Viel-Thériault I, Martin B, Thompson-Desormeaux F, Blackburn J, Moussa A, Autmizguine J. Vancomycin drug monitoring in infants with CoNS sepsis-target attainment, microbiological response and nephrotoxicity. J Perinatol 2020; 40:97-104. [PMID: 31576000 DOI: 10.1038/s41372-019-0519-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To characterize residual vancomycin concentrations (Cmin) and assess the relationships between Cmin, the risk of nephrotoxicity and persistent CoNS sepsis. METHODS In this 5-year retrospective study among infants treated with vancomycin, the primary outcome was the proportion of those with a steady state Cmin between 10 and 20 mg/L. The secondary outcomes were nephrotoxicity and persistent CoNS sepsis. RESULTS Of 120 infants included, the median first steady state Cmin was 12.4 mg/L and 77 (64%) had a Cmin between 10 and 20 mg/L. Six percent developed nephrotoxicity. This risk was not associated with Cmin. Of the 30 infants with CoNS sepsis, 17 (57%) had persistent bacteremia, and this risk did not correlate significantly with Cmin, CoNS minimal inhibitory concentration (MIC) for vancomycin, or Cmin/MIC. CONCLUSIONS The majority of infants achieved targeted levels of vancomycin, but persistent bacteremia was common. We did not identify a Cmin threshold associated with nephrotoxicity, nor with microbiological clearance.
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Affiliation(s)
| | - Brigitte Martin
- Department of Pharmacy, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Julie Blackburn
- Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montreal, QC, Canada
| | - Ahmed Moussa
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Julie Autmizguine
- Department of Pediatrics, Université de Montréal, Montreal, QC, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, QC, Canada.,Clinical Pharmacology Unit, Université de Montréal, Montreal, QC, Canada
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Pham JT. Challenges of Vancomycin Dosing and Therapeutic Monitoring in Neonates. J Pediatr Pharmacol Ther 2020; 25:476-484. [PMID: 32839651 PMCID: PMC7439954 DOI: 10.5863/1551-6776-25.6.476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2020] [Indexed: 11/11/2022]
Abstract
Late-onset sepsis in neonates can lead to significant morbidity and mortality, especially in preterm infants. Vancomycin is commonly prescribed for the treatment of Gram-positive organisms, particularly methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci, and ampicillin-resistant Enterococcus species in adult and pediatric patients. Currently, there is no consensus on optimal dosing and monitoring of vancomycin in neonates. Different vancomycin dosing regimens exist for neonates, but with many of these regimens, obtaining therapeutic trough concentrations can be difficult. In 2011, the Infectious Diseases Society of America recommended vancomycin trough concentrations of 15 to 20 mg/L or an AUC/MIC ratio of ≥400 for severe invasive diseases (e.g., MRSA) in adult and pediatric patients. Owing to recent reports of increased risk of nephrotoxicity associated with vancomycin trough concentrations of 15 to 20 mg/L and AUC/MIC of ≥400, a revised consensus guideline, recently published in 2020, no longer recommends monitoring vancomycin trough concentrations in adult patients. The guideline recommends an AUC/MIC of 400 to 600, which has been found to achieve clinical efficacy while reducing nephrotoxicity. However, these recommendations were derived solely from adult literature, as there are limited clinical outcomes data in pediatric and neonatal patients. Furthermore, owing to the variation of vancomycin pharmacokinetic parameters among the neonatal population, these recommendations for achieving vancomycin AUC/MIC of 400 to 600 in neonates require further investigation. This review will discuss the challenges of achieving optimal vancomycin dosing and monitoring in neonatal patients.
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Allegaert K, Flint R, Smits A. Pharmacokinetic modelling and Bayesian estimation-assisted decision tools to optimize vancomycin dosage in neonates: only one piece of the puzzle. Expert Opin Drug Metab Toxicol 2019; 15:735-749. [PMID: 31402708 DOI: 10.1080/17425255.2019.1655540] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Vancomycin is commonly administered to neonates, while observational data on therapeutic drug monitoring (TDM, trough levels) suggest that vancomycin exposure and dosage remain substandard. Area covered: Data on vancomycin pharmacokinetics (PK) and its covariates are abundant. Consequently, modeling is an obvious tool to improve targeted exposure, with a shift from TDM trough levels to area under the curve (AUC24h) targets, as in adults. Continuous administration appeared as a practice to facilitate AUC24h target attainment, while Bayesian model-supported targeting emerged as a novel tool. However, the AUC24h/MIC (minimal inhibitory concentration) target itself should consider neonate-specific aspects (bloodstream infections, coagulase-negative staphylococci, protein binding, underexplored causes of variability, like assays, preparation and administration inaccuracies, or missing covariates). Expert opinion: To improve targeted exposure in neonates, initial vancomycin prescription should be based on 'a priori model-based individual dosing' using validated dosing regimens, followed by further tailoring by dosing optimization applying Bayesian estimation-assisted TDM. Future research should focus on the feasibility to integrate these tools (individualized dosing, Bayesian models) in clinical practice, and to perform PK/PD studies in the relevant animal models and human neonatal setting (coagulase-negative staphylococci, bloodstream infections).
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Affiliation(s)
- Karel Allegaert
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Development and Regeneration, KU Leuven , Leuven , Belgium
| | - Robert Flint
- Department of Pediatrics, Division of Neonatology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam , Rotterdam , the Netherlands.,Department of Pharmacy, Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven , Leuven , Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven , Leuven , Belgium
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Reilly AM, Ding MX, Rower JE, Kiser TH. The Effectiveness of a Vancomycin Dosing Guideline in the Neonatal Intensive Care Unit for Achieving Goal Therapeutic Trough Concentrations. J Clin Pharmacol 2019; 59:997-1005. [PMID: 30776089 DOI: 10.1002/jcph.1392] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/28/2019] [Indexed: 11/06/2022]
Abstract
Concern for bacterial resistance and treatment failure with vancomycin trough concentrations < 10 μg/mL have led guidelines to increase goal concentrations. There is a paucity of data evaluating vancomycin dosage necessary to achieve goals in the neonatal intensive care unit (NICU). We aimed to evaluate the implementation of a new vancomycin dosing guideline in improving trough target attainment. This retrospective study evaluated neonates in the NICU treated with vancomycin between January 2009 and December 2015. Therapeutic trough concentration attainment (10-20 μg/mL) was compared between neonates receiving vancomycin per old versus new dosing guidelines. Vancomycin trough concentrations, modeled pharmacodynamic target attainment, and nephrotoxicity were compared between groups. A total of 212 vancomycin trough concentrations (n = 91 old and n = 121 new guideline) were evaluated in 182 unique neonates. The mean ± standard deviation trough concentration achieved was 18.0 ± 7.3 μg/mL vs 8.9 ± 4.8 μg/mL in the new and old guidelines, respectively (P < .01). The new guideline resulted in a higher percentage of neonates achieving trough concentrations of 10 to 20 μg/mL (62% vs 29%; P < .01) and decreased the percentage of neonates with subtherapeutic trough concentrations (9% vs 69%; P < .01). Pharmacokinetic modeling identified postmenstrual age, days of life, and urine output as predictors of vancomycin clearance and resultant trough and area under the curve values (P < .01 for all). Trough concentrations >10 μg/mL ensured area under the curve /minimum inhibitory concentration >400 in >90% of neonates when bacteria minimum inhibitory concentration was ≤ 1 μg/mL. Nephrotoxicity was similar between groups (8.3% vs 7.7%; P = .99). In conclusion, a vancomycin nomogram designed to achieve trough concentration of 10 to 20 μg/mL improves pharmacodynamic target attainment in neonates in the NICU.
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Affiliation(s)
- Ashley M Reilly
- Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Michelle X Ding
- Department of Pharmacy, Kaiser Permanente, Los Angeles, CA, USA
| | - Joseph E Rower
- Department of Pharmacology and Toxicology, University of Utah Skaggs College of Pharmacy, Salt Lake City, UT, USA
| | - Tyree H Kiser
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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Sargel CL, Thompson RZ, Brax A. Vancomycin Pharmacokinetics During Extracorporeal Membrane Oxygenation and Dosing Targets-A Constantly Moving Target? Pediatr Crit Care Med 2018; 19:1002-1003. [PMID: 30281571 DOI: 10.1097/pcc.0000000000001689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Cheryl L Sargel
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, OH
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Pharmacokinetics, Tissue Distribution and Excretion of a Novel Diuretic (PU-48) in Rats. Pharmaceutics 2018; 10:pharmaceutics10030124. [PMID: 30096833 PMCID: PMC6160999 DOI: 10.3390/pharmaceutics10030124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/21/2018] [Accepted: 07/27/2018] [Indexed: 01/02/2023] Open
Abstract
Methyl 3-amino-6-methoxythieno [2,3-b] quinoline-2-carboxylate (PU-48) is a novel diuretic urea transporter inhibitor. The aim of this study is to investigate the profile of plasma pharmacokinetics, tissue distribution, and excretion by oral dosing of PU-48 in rats. Concentrations of PU-48 within biological samples are determined using a validated high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. After oral administration of PU-48 (3, 6, and 12 mg/kg, respectively) in self-nanomicroemulsifying drug delivery system (SNEDDS) formulation, the peak plasma concentrations (Cmax), and the area under the curve (AUC0⁻∞) were increased by the dose-dependent and linear manner, but the marked different of plasma half-life (t1/2) were not observed. This suggests that the pharmacokinetic profile of PU-48 prototype was first-order elimination kinetic characteristics within the oral three doses range in rat plasma. Moreover, the prototype of PU-48 was rapidly and extensively distributed into thirteen tissues, especially higher concentrations were detected in stomach, intestine, liver, kidney, and bladder. The total accumulative excretion of PU-48 in the urine, feces, and bile was less than 2%. This research is the first report on disposition via oral administration of PU-48 in rats, and it provides important information for further development of PU-48 as a diuretic drug candidate.
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