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Kim HK, Jeong TD, Ji M, Kim S, Lee W, Chun S. Automated calculation and reporting of vancomycin area under the concentration-time curve: a simplified single-trough concentration-based equation approach. Antimicrob Agents Chemother 2024:e0069924. [PMID: 39194211 DOI: 10.1128/aac.00699-24] [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: 05/10/2024] [Accepted: 08/07/2024] [Indexed: 08/29/2024] Open
Abstract
Vancomycin, a crucial antibiotic for Gram-positive bacterial infections, requires therapeutic drug monitoring (TDM). Contemporary guidelines advocate for AUC-based monitoring; however, using Bayesian programs for AUC estimation poses challenges. We aimed to develop and evaluate a simplified AUC estimation equation using a steady-state trough concentration (Ctrough) value. Utilizing 1,034 TDM records from 580 general hospitalized patients at a university-affiliated hospital in Ulsan, we created an equation named SSTA that calculates the AUC by applying Ctrough, body weight, and single dose as input variables. External validation included 326 records from 163 patients at a university-affiliated hospital in Seoul (EWUSH) and literature data from 20 patients at a university-affiliated hospital in Bangkok (MUSI). It was compared with other AUC estimation models based on the Ctrough, including a linear regression model (LR), a sophisticated model based on the first-order equation (VancoPK), and a Bayesian model (BSCt). Evaluation metrics, such as median absolute percentage error (MdAPE) and the percentage of observations within ±20% error (P20), were calculated. External validation using the EWUSH data set showed that SSTA, LR, VancoPK, and BSCt had MdAPE values of 6.4, 10.1, 6.6, and 7.5% and P20 values of 87.1, 82.5, 87.7, and 83.4%, respectively. External validation using the MUSI data set showed that SSTA, LR, and VancoPK had MdAPEs of 5.2, 9.4, and 7.2%, and P20 of 95, 90, and 95%, respectively. Owing to its decent AUC prediction performance, simplicity, and convenience for automated calculation and reporting, SSTA could be used as an adjunctive tool for the AUC-based TDM.
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Affiliation(s)
- Hyun-Ki Kim
- Department of Laboratory Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Tae-Dong Jeong
- Department of Laboratory Medicine, Ewha Womans University College of Medicine, Seoul, South Korea
| | - Misuk Ji
- Department of Laboratory Medicine, Veterans Health Service (VHS) Medical Center, Seoul, South Korea
| | - Sollip Kim
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Woochang Lee
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
| | - Sail Chun
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, South Korea
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2
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Aguilo Lafarga I, Pérez Moreno M, Herranz Bayo E, Merchante Andreu M, Huarte Lacunza R. Recommended doses of endovenous vancomycin are insufficient to achieve therapeutic concentrations in paediatric patients. Eur J Hosp Pharm 2024; 31:474-479. [PMID: 37105712 DOI: 10.1136/ejhpharm-2023-003694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVES Vancomycin therapeutic drug monitoring is challenging, especially in the paediatric population where evidence is scarce. The main objective of this study was to analyse the achievement of therapeutic concentrations of vancomycin in paediatric patients and to evaluate the current monitoring method (trough levels), doses used, and the time required to achieve target concentrations. METHODS Paediatric patients on treatment and monitored with vancomycin from November 2019 to December 2021 were included. Those with only one determination of serum vancomycin concentration were excluded. Demographic variables, analytical and microbiological parameters and toxicity data were collected. Pharmacokinetic parameters were assessed at baseline and during treatment. RESULTS 225 patients (40.9% female; 108 neonates, 49 infants and 68 children or adolescents) were included in the study. The main indications for vancomycin treatment were sepsis (33.9%) and fever of unknown origin (29.3%). Microbiological cultures were positive in 71.1%, mostly with Gram-positive bacteria (60.4%). Therapeutic levels of vancomycin were reached in only 20.1% of the participants in the first determination. After pharmacokinetic monitoring, 81.7% of patients reached therapeutic concentrations, requiring a 23% increase in the initial dose, a 2-day lag time and 1-2 dosage adjustments until the therapeutic concentration was reached. Of the total patients, 13 developed nephrotoxicity, nine neutropenia and one patient developed red man syndrome. CONCLUSIONS In our sample of paediatric patients, the recommended doses of vancomycin were insufficient to achieve therapeutic concentrations. Revision of the recommendations and/or a change in the method of pharmacokinetic monitoring is crucial to optimise treatment in this population.
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Affiliation(s)
| | - María Pérez Moreno
- Pharmacy Service, Hospital Universitario Miguel Servet, Zaragoza, Aragon, Spain
| | - Elena Herranz Bayo
- Pharmacy Service, Hospital Universitario Miguel Servet, Zaragoza, Aragon, Spain
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3
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Minichmayr IK, Dreesen E, Centanni M, Wang Z, Hoffert Y, Friberg LE, Wicha SG. Model-informed precision dosing: State of the art and future perspectives. Adv Drug Deliv Rev 2024:115421. [PMID: 39159868 DOI: 10.1016/j.addr.2024.115421] [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: 06/18/2024] [Revised: 07/19/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024]
Abstract
Model-informed precision dosing (MIPD) stands as a significant development in personalized medicine to tailor drug dosing to individual patient characteristics. MIPD moves beyond traditional therapeutic drug monitoring (TDM) by integrating mathematical predictions of dosing, and considering patient-specific factors (patient characteristics, drug measurements) as well as different sources of variability. For this purpose, rigorous model qualification is required for the application of MIPD in patients. This review delves into new methods in model selection and validation, also highlighting the role of machine learning in improving MIPD, the utilization of biosensors for real-time monitoring, as well as the potential of models integrating biomarkers for efficacy or toxicity for precision dosing. The clinical evidence of TDM and MIPD is discussed for various medical fields including infection medicine, oncology, transplant medicine, and inflammatory bowel diseases, thereby underscoring the role of pharmacokinetics/pharmacodynamics and specific biomarkers. Further research, particularly randomized clinical trials, is warranted to corroborate the value of MIPD in enhancing patient outcomes and advancing personalized medicine.
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Affiliation(s)
- I K Minichmayr
- Dept. of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - E Dreesen
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - M Centanni
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Z Wang
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Y Hoffert
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - L E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - S G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany.
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4
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Williams P, Cotta MO, Tabah A, Sandaradura I, Kanji S, Scheetz MH, Imani S, Elhadi M, Pardos SL, Schellack N, Sanches C, Timsit JF, Xie J, Farkas A, Wilks K, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients - An international perspective on access, utilisation, and barriers. Int J Antimicrob Agents 2024; 64:107192. [PMID: 38734215 DOI: 10.1016/j.ijantimicag.2024.107192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) is an effective method for individualising antimicrobial therapy in critically ill patients. The 2021 ADMIN-intensive care unit survey studied a wide range of intensive care unit clinicians worldwide to gain their perspectives on antimicrobial TDM. This article reports the responses from this survey relating to TDM access, utilisation, and barriers. METHODS An online survey consisted of multiple-choice questions and 5-point Likert scales. The survey examined respondent's access to minimum inhibitory concentration (MIC) results, drug assays, and dosing software, as well as barriers to TDM. RESULTS The survey included 538 clinicians from 409 hospitals in 45 countries, with 71% physicians and 29% pharmacists. Despite most respondents having access to assays, 21% and 26% of respondents lacked access to vancomycin and aminoglycosides, respectively. In lower-income countries, almost 40% reported no access. Delayed drug assay turnaround time was the most significant barrier to TDM, particularly in lower-income countries. Routine access to MIC results was unavailable for 41% of respondents, with 25% of lower-income country respondents having no access to MIC or susceptibility reports. CONCLUSIONS This global survey indicated that consistent TDM usage is hindered by assay access in some sites and the timeliness of assay results in others. Addressing barriers to TDM, particularly in low-income countries, should be a priority to ensure equitable access to affordable TDM.
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Affiliation(s)
- Paul Williams
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia.
| | - Menino Osbert Cotta
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia; Queensland University of Technology, Brisbane, Queensland, Australia
| | - Indy Sandaradura
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia; Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Sydney, New South Wales, Australia
| | - Salmaan Kanji
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marc H Scheetz
- Pharmacometric Center of Excellence, Departments of Pharmacy Practice and Pharmacology, College of Pharmacy, Midwestern University, Downers Grove, Illinois, USA
| | - Sahand Imani
- Nepean Blue Mountains Local Health District, Nepean Hospital, Sydney, New South Wales, Australia
| | | | - Sònia Luque Pardos
- Pharmacy Department, Parc de Salut Mar, Barcelona, Spain; Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; CIBER of Pharmacy, Saint Clare's Infectious Diseases (CIBERINFEC CB21/13/0002) Institute of Health Carlos III, Madrid, Spain
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Cristina Sanches
- Campus Centro Oeste Dona Lindu, Federal University of Sao João del Rei, Divinópolis, Minas Gerais, Brazil
| | - Jean Francois Timsit
- Assistance Publique Hôpitaux de Paris - Bichat Hospital Medical and Infectious Diseases ICU (MI2), Paris France; IAME U 1137 Université Paris-Cité Site Bichat, Paris, France
| | - Jiao Xie
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Andras Farkas
- Optimum Dosing Strategies, Bloomingdale, New Jersey, USA; Department of Pharmacy, Saint Clare's Health, Denville, New Jersey, USA
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia; School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Queensland, Australia; Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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Wong S, Selby PR, Reuter SE. Determination of a vancomycin nephrotoxicity threshold and assessment of target attainment in hematology patients. Pharmacol Res Perspect 2024; 12:e1231. [PMID: 38940223 PMCID: PMC11211924 DOI: 10.1002/prp2.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024] Open
Abstract
An area-under-the-curve (AUC24)-based approach is recommended to guide vancomycin therapeutic drug monitoring (TDM), yet trough concentrations are still commonly used despite associated risks. A definitive toxicity target is lacking, which is important for hematology patients who have a higher risk of nephrotoxicity. The aims were to (1) assess the impact of trough-based TDM on acute kidney injury (AKI) incidence, (2) establish a vancomycin nephrotoxicity threshold, and (3) evaluate the proportion of hematology patients achieving vancomycin therapeutic targets. Retrospective data was collected from 100 adult patients with a hematological malignancy or aplastic anemia who received vancomycin between April 2020 and January 2021. AKI occurrence was determined based on serum creatinine concentrations, and individual pharmacokinetic parameters were estimated using a Bayesian approach. Receiver operating characteristic (ROC) curve analysis was performed to assess the ability of pharmacokinetic indices to predict AKI occurrence. The proportion of patients who achieved target vancomycin exposure was evaluated based on an AUC24/MIC ≥400 and the determined toxicity threshold. The incidence of AKI was 37%. ROC curve analysis indicated a maximum AUC24 of 644 mg.h/L over the treatment period was an important predictor of AKI. By Day 4 of treatment, 29% of treatment courses had supratherapeutic vancomycin exposure, with only 62% of courses achieving AUC24 targets. The identified toxicity threshold supports an AUC24 target range of 400-650 mg.h/L, assuming an MIC of 1 mg/L, to optimize vancomycin efficacy and minimize toxicity. This study highlights high rates of AKI in this population and emphasizes the importance of transitioning from trough-based TDM to an AUC-based approach to improve clinical outcomes.
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Affiliation(s)
- Sherilyn Wong
- UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
| | - Philip R. Selby
- UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
- School of MedicineThe University of AdelaideAdelaideSouth AustraliaAustralia
- SA Pharmacy, Royal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Stephanie E. Reuter
- UniSA Clinical and Health SciencesUniversity of South AustraliaAdelaideSouth AustraliaAustralia
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Dyer CJ, De Waele JJ, Roberts JA. Antibiotic dose optimisation in the critically ill: targets, evidence and future strategies. Curr Opin Crit Care 2024:00075198-990000000-00194. [PMID: 39150038 DOI: 10.1097/mcc.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To highlight the recent evidence for antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in enhancing patient outcomes in sepsis and septic shock. We also summarise the limitations of available data and describe future directions for research to support translation of antibiotic dose optimisation to the clinical setting. RECENT FINDINGS Sepsis and septic shock are associated with poor outcomes and require antibiotic dose optimisation, mostly due to significantly altered pharmacokinetics. Many studies, including some randomised controlled trials have been conducted to measure the clinical outcome effects of antibiotic dose optimisation interventions including use of therapeutic drug monitoring. Current data support antibiotic dose optimisation for the critically ill. Further investigation is required to evolve more timely and robust precision antibiotic dose optimisation approaches, and to clearly quantify whether any clinical and health-economic benefits support expanded use of this treatment intervention. SUMMARY Antibiotic dose optimisation appears to improve outcomes in critically ill patients with sepsis and septic shock, however further research is required to quantify the level of benefit and develop a stronger knowledge of the role of new technologies to facilitate optimised dosing.
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Affiliation(s)
- Christopher J Dyer
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital
- Dept of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jason A Roberts
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia
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7
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Telles JP, Coelho D, Migotto KC, Diegues MS, Leao ER, Reghini R, Martinez Martos N, Caruso P, França E Silva IL. Switching Vancomycin Monitoring From Trough Concentration to Area Under the Curve Estimation by Bayesian Forecasting: A Short Communication on a Cost-Benefit Study in Resource-Limited Settings. Ther Drug Monit 2024:00007691-990000000-00222. [PMID: 38967524 DOI: 10.1097/ftd.0000000000001223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/25/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND This study was conducted to evaluate the cost-benefit indicators of a vancomycin monitoring protocol based on area under the curve estimation using commercial Bayesian software. METHODS This quasi-experimental study included patients who were aged >18 years with a vancomycin prescription for >24 hours. Patients who were terminally ill or those with acute kidney injury (AKI) ≤24 hours were excluded. During the preintervention period, doses were adjusted based on the trough concentration target of 15-20 mg/L, whereas the postintervention period target was 400-500 mg × h/L for the area under the curve. The medical team was responsible for deciding to stop the antimicrobial prescription without influence from the therapeutic drug monitoring team. The main outcomes were the incidence of AKI and length of stay. Cost-benefit simulation was performed after statistical analysis. RESULTS There were 96 patients in the preintervention group and 110 in the postintervention group. The AKI rate decreased from 20% (n = 19) to 6% (n = 6; P = 0.003), whereas the number of vancomycin serum samples decreased from 5 (interquartile range: 2-7) to 2 (interquartile range: 1-3) examinations per patient (P < 0.001). The mean length of hospital stay for patients was 26.19 days after vancomycin prescription, compared with 17.13 days for those without AKI (P = 0.003). At our institution, the decrease in AKI rate and reduced length of stay boosted yearly savings of up to US$ 369,000 for 300 patients receiving vancomycin therapy. CONCLUSIONS Even in resource-limited settings, a commercial Bayesian forecasting-based protocol for vancomycin is important for determining cost-benefit outcomes.
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Affiliation(s)
- João Paulo Telles
- Department of Infectious Diseases, AC Camargo Cancer Center, São Paulo, Brazil
| | - Diogenes Coelho
- Department of Infectious Diseases, AC Camargo Cancer Center, São Paulo, Brazil
| | | | | | - Erica Rocha Leao
- Department of Pharmacy, AC Camargo Cancer Center, São Paulo, Brazil
| | - Rodrigo Reghini
- Department of Infectious Diseases, AC Camargo Cancer Center, São Paulo, Brazil
| | | | - Pedro Caruso
- Department of Intensive Care Medicine, AC Camargo Cancer Center, São Paulo, Brazil
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Roger C. Understanding antimicrobial pharmacokinetics in critically ill patients to optimize antimicrobial therapy: A narrative review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:287-298. [PMID: 39035618 PMCID: PMC11258509 DOI: 10.1016/j.jointm.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 07/23/2024]
Abstract
Effective treatment of sepsis not only demands prompt administration of appropriate antimicrobials but also requires precise dosing to enhance the likelihood of patient survival. Adequate dosing refers to the administration of doses that yield therapeutic drug concentrations at the infection site. This ensures a favorable clinical and microbiological response while avoiding antibiotic-related toxicity. Therapeutic drug monitoring (TDM) is the recommended approach for attaining these goals. However, TDM is not universally available in all intensive care units (ICUs) and for all antimicrobial agents. In the absence of TDM, healthcare practitioners need to rely on several factors to make informed dosing decisions. These include the patient's clinical condition, causative pathogen, impact of organ dysfunction (requiring extracorporeal therapies), and physicochemical properties of the antimicrobials. In this context, the pharmacokinetics of antimicrobials vary considerably between different critically ill patients and within the same patient over the course of ICU stay. This variability underscores the need for individualized dosing. This review aimed to describe the main pathophysiological changes observed in critically ill patients and their impact on antimicrobial drug dosing decisions. It also aimed to provide essential practical recommendations that may aid clinicians in optimizing antimicrobial therapy among critically ill patients.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Nîmes, France
- UR UM 103 IMAGINE (Initial Management and prévention of orGan failures IN critically ill patiEnts), Faculty of Medicine, Montpellier University, Montpellier, France
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9
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Shen X, Li X, Lu J, Zhu J, He Y, Zhang Z, Chen Z, Zhang J, Fan X, Li W. Population pharmacokinetic analysis for dose regimen optimization of vancomycin in Southern Chinese children. CPT Pharmacometrics Syst Pharmacol 2024; 13:1201-1213. [PMID: 38686551 PMCID: PMC11247118 DOI: 10.1002/psp4.13151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/19/2024] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
Changes in physiological factors may result in large pharmacokinetic variability of vancomycin in pediatric patients, thereby leading to either supratherapeutic or subtherapeutic exposure and potentially affecting clinical outcomes. This study set out to characterize the disposition of vancomycin, quantify the exposure target and establish an optimal dosage regimen among the Southern Chinese pediatric population. Routine therapeutic drug monitoring data of 453 patients were available. We performed a retrospective population pharmacokinetic analysis of hospitalized children prescribed intravenous vancomycin using NONMEM® software. A one-compartment PPK model of vancomycin with body weight and renal functions as covariates based on a cutoff of 2 years old children was proposed in this study. Both internal and external validation showing acceptable and robust predictive performance of the model to estimate PK parameters. The value of area under the curve over 24 h to minimum inhibitory concentration ratio (AUC0-24/MIC) ≥ 260 was a significant predictor for therapeutic efficacy. Monte Carlo simulations served as a model-informed precision dosing approach and suggested that different optimal dose regimens in various scenarios should be considered rather than flat dosing. The evaluation of vancomycin exposure-efficacy relationship indicated that lower target level of AUC0-24/MIC may be needed to achieve clinical effectiveness in children, which was used to derive the recommended dosing regimen. Further prospective studies will be needed to corroborate and elucidate these results.
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Affiliation(s)
- Xianhuan Shen
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Xuejuan Li
- Shenzhen Children's HospitalShenzhenChina
| | - Jieluan Lu
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Jiahao Zhu
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Yaodong He
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Zhou Zhang
- Shenzhen Children's HospitalShenzhenChina
| | - Zebin Chen
- Shenzhen Children's HospitalShenzhenChina
| | | | - Xiaomei Fan
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
- College of PharmacyJinan UniversityGuangzhouChina
| | - Wenzhou Li
- Shenzhen Baoan Women's and Children's HospitalJinan UniversityShenzhenChina
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10
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Soeorg H, Kalamees R, Lutsar I, Metsvaht T. Subgroup identification-based model selection to improve the predictive performance of individualized dosing. J Pharmacokinet Pharmacodyn 2024; 51:253-263. [PMID: 38400995 DOI: 10.1007/s10928-024-09909-8] [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: 07/17/2023] [Accepted: 02/13/2024] [Indexed: 02/26/2024]
Abstract
Currently, model-informed precision dosing uses one population pharmacokinetic model that best fits the target population. We aimed to develop a subgroup identification-based model selection approach to improve the predictive performance of individualized dosing, using vancomycin in neonates/infants as a test case. Data from neonates/infants with at least one vancomycin concentration was randomly divided into training and test dataset. Population predictions from published vancomycin population pharmacokinetic models were calculated. The single best-performing model based on various performance metrics, including median absolute percentage error (APE) and percentage of predictions within 20% (P20) or 60% (P60) of measurement, were determined. Clustering based on median APEs or clinical and demographic characteristics and model selection by genetic algorithm was used to group neonates/infants according to their best-performing model. Subsequently, classification trees to predict the best-performing model using clinical and demographic characteristics were developed. A total of 208 vancomycin treatment episodes in training and 88 in test dataset was included. Of 30 identified models from the literature, the single best-performing model for training dataset had P20 26.2-42.6% in test dataset. The best-performing clustering approach based on median APEs or clinical and demographic characteristics and model selection by genetic algorithm had P20 44.1-45.5% in test dataset, whereas P60 was comparable. Our proof-of-concept study shows that the prediction of the best-performing model for each patient according to the proposed model selection approaches has the potential to improve the predictive performance of model-informed precision dosing compared with the single best-performing model approach.
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Affiliation(s)
- Hiie Soeorg
- Department of Microbiology, University of Tartu, Ravila 19, Tartu, 50411, Estonia.
| | - Riste Kalamees
- Department of Microbiology, University of Tartu, Ravila 19, Tartu, 50411, Estonia
| | - Irja Lutsar
- Department of Microbiology, University of Tartu, Ravila 19, Tartu, 50411, Estonia
| | - Tuuli Metsvaht
- Department of Microbiology, University of Tartu, Ravila 19, Tartu, 50411, Estonia
- Pediatric Intensive Care Unit, Tartu University Hospital, Puusepa 8, Tartu, 50406, Estonia
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11
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McClure S, McElroy L, Gugkaeva Z. Implementation of vancomycin AUC/MIC dosing vs traditional trough dosing and incidence of acute kidney injury at a rural community hospital. Am J Health Syst Pharm 2024; 81:e283-e288. [PMID: 38253056 DOI: 10.1093/ajhp/zxae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Indexed: 01/24/2024] Open
Abstract
PURPOSE Vancomycin treats methicillin-resistant Staphylococcus aureus infections in hospitalized patients, yet nephrotoxicity is a major risk. Dosing based on the ratio of vancomycin 24-hour area under the curve to minimum inhibitory concentration (AUC/MIC) is preferred over a trough-only vancomycin dosing approach to minimize the risk of acute kidney injury (AKI). This study compares the safety of AUC/MIC-guided and trough-only vancomycin dosing at a 255-bed hospital. METHODS A retrospective cohort study of adult patients with stable renal function who received at least 3 days of intravenous vancomycin via either AUC/MIC or trough-only dosing was conducted. The primary outcome was AKI occurrence during treatment. Secondary outcomes included the frequencies of therapeutic, subtherapeutic, and supratherapeutic vancomycin troughs. Relative risk calculations were performed for all outcomes. RESULTS 600 patients from the trough-only group and 561 patients from the AUC/MIC group were included. 121 patients from the trough-only group and 87 patients from the AUC/MIC group experienced AKI during treatment (relative risk [RR], 0.769; 95% CI, 0.599-0.988; P = 0.0397). Compared with the trough-only group, the AUC/MIC group was significantly less likely to have supratherapeutic troughs (RR, 0.703; 95% CI, 0.611-0.809; P < 0.0001) and significantly more likely to have therapeutic troughs (RR, 1.14; 95% CI, 1.069-1.211; P < 0.0001), with no significant between-group difference in subtherapeutic troughs (RR, 1.03; 95% CI, 0.854-1.25; P = 0.74). CONCLUSION AUC/MIC dosing was associated with significantly lower risk of AKI, a lower risk of supratherapeutic trough levels, and a higher risk of therapeutic trough levels, with no significant difference in subtherapeutic troughs when compared to trough-only dosing. Limitations of this study included its retrospective nature and reliance on manual chart review.
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12
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Chen G, Sun K, Michon I, Barter Z, Neuhoff S, Ghosh L, Ilic K, Song IH. Physiologically Based Pharmacokinetic Modeling for Maribavir to Inform Dosing in Drug-Drug Interaction Scenarios with CYP3A4 Inducers and Inhibitors. J Clin Pharmacol 2024; 64:590-600. [PMID: 38009271 DOI: 10.1002/jcph.2385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/14/2023] [Indexed: 11/28/2023]
Abstract
Maribavir, an orally available antiviral agent, has been approved in multiple countries for the treatment of patients with refractory post-transplant cytomegalovirus (CMV) infection and/or disease. Maribavir is primarily metabolized by CYP3A4; coadministration with CYP3A4 inducers and inhibitors may significantly alter maribavir exposure, thereby affecting its efficacy and safety. The effect of CYP3A4 inducers and inhibitors on maribavir exposure was evaluated based on a drug-drug interaction (DDI) study and physiologically-based pharmacokinetic (PBPK) modeling. The effect of rifampin (a strong inducer of CYP3A4 and moderate inducer of CYP1A2), administered at a 600 mg dose once daily, on maribavir pharmacokinetics was assessed in a clinical phase 1 DDI study in healthy participants. A full PBPK model for maribavir was developed and verified using in vitro and clinical pharmacokinetic data from phase 1 studies. The verified PBPK model was then used to simulate maribavir DDI interactions with various CYP3A4 inducers and inhibitors. The DDI study results showed that coadministration with rifampin decreased the maribavir maximum plasma concentration (Cmax), area under the plasma concentration-time curve (AUC), and trough concentration (Ctrough) by 39%, 60%, and 82%, respectively. Based on the results from the clinical DDI study, the coadministration of maribavir with rifampin is not recommended. The PBPK model did not predict a clinically significant effect of CYP3A4 inhibitors on maribavir exposure; however, it predicted that strong or moderate CYP3A4 inducers, including carbamazepine, efavirenz, phenobarbital, and phenytoin, may reduce maribavir exposure to a clinically significant extent, and may prompt the consideration of a maribavir dosing increase, in accordance with local approved labels and/or regulations.
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Affiliation(s)
- Grace Chen
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Kefeng Sun
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | | | - Zoe Barter
- Certara UK Ltd., Simcyp Division, Sheffield, UK
| | | | - Lipika Ghosh
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Katarina Ilic
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Ivy H Song
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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13
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Armstrong Cook J, Pouliot J, Parker R. Out With the Old, in With the New: What Rising Pharmacists Need to Know About Vancomycin Therapeutic Drug Monitoring in Adults. J Pharm Pract 2024; 37:261-264. [PMID: 36607606 DOI: 10.1177/08971900221150321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The goal of this commentary is to provide recent pharmacy school graduates and student pharmacists completing APPEs the essential background for correct vancomycin therapeutic drug monitoring (TDM) in the inpatient setting.
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Affiliation(s)
- Jessica Armstrong Cook
- College of Pharmacy, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - Jonathan Pouliot
- College of Pharmacy, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
- Department of Pharmacy and Pharmaceutical Sciences, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - Robin Parker
- College of Pharmacy, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
- Department of Pharmacy and Pharmaceutical Sciences, Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
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14
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Chai MG, Tu Q, Cotta MO, Bauer MJ, Balch R, Okafor C, Comans T, Kruger P, Meyer J, Shekar K, Brady K, Fourie C, Sharp N, Vlad L, Whiley D, Ungerer JPJ, Mcwhinney BC, Farkas A, Paterson DL, Clark JE, Hajkowicz K, Raman S, Bialasiewicz S, Lipman J, Forde BM, Harris PNA, Schlapbach LJ, Coin L, Roberts JA, Irwin AD. Achievement of therapeutic antibiotic exposures using Bayesian dosing software in critically unwell children and adults with sepsis. Intensive Care Med 2024; 50:539-547. [PMID: 38478027 PMCID: PMC11018654 DOI: 10.1007/s00134-024-07353-3] [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: 10/29/2023] [Accepted: 02/11/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE Early recognition and effective treatment of sepsis improves outcomes in critically ill patients. However, antibiotic exposures are frequently suboptimal in the intensive care unit (ICU) setting. We describe the feasibility of the Bayesian dosing software Individually Designed Optimum Dosing Strategies (ID-ODS™), to reduce time to effective antibiotic exposure in children and adults with sepsis in ICU. METHODS A multi-centre prospective, non-randomised interventional trial in three adult ICUs and one paediatric ICU. In a pre-intervention Phase 1, we measured the time to target antibiotic exposure in participants. In Phase 2, antibiotic dosing recommendations were made using ID-ODS™, and time to target antibiotic concentrations were compared to patients in Phase 1 (a pre-post-design). RESULTS 175 antibiotic courses (Phase 1 = 123, Phase 2 = 52) were analysed from 156 participants. Across all patients, there was no difference in the time to achieve target exposures (8.7 h vs 14.3 h in Phase 1 and Phase 2, respectively, p = 0.45). Sixty-one courses in 54 participants failed to achieve target exposures within 24 h of antibiotic commencement (n = 36 in Phase 1, n = 18 in Phase 2). In these participants, ID-ODS™ was associated with a reduction in time to target antibiotic exposure (96 vs 36.4 h in Phase 1 and Phase 2, respectively, p < 0.01). These patients were less likely to exhibit subtherapeutic antibiotic exposures at 96 h (hazard ratio (HR) 0.02, 95% confidence interval (CI) 0.01-0.05, p < 0.01). There was no difference observed in in-hospital mortality. CONCLUSIONS Dosing software may reduce the time to achieve target antibiotic exposures. It should be evaluated further in trials to establish its impact on clinical outcomes.
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Affiliation(s)
- Ming G Chai
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Quyen Tu
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Menino O Cotta
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- Herston Infectious Disease Institute, Metro North, QLD Health, Herston, QLD, Australia
| | - Michelle J Bauer
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Ross Balch
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Charles Okafor
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Tracy Comans
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Jason Meyer
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Kara Brady
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Cheryl Fourie
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Natalie Sharp
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Luminita Vlad
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - David Whiley
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Jacobus P J Ungerer
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
- Faculty of Biomedical Science, University of Queensland, Brisbane, QLD, Australia
| | - Brett C Mcwhinney
- Department of Chemical Pathology, Pathology Queensland, Brisbane, QLD, Australia
| | - Andras Farkas
- Optimum Dosing Strategies, Bloomingdale, NJ, 07403, USA
- Department of Pharmacy, Saint Clare's Health, Denville, NJ, 07834, USA
| | - David L Paterson
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Julia E Clark
- Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Australia
| | - Krispin Hajkowicz
- Department of Infectious Diseases, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Sainath Raman
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Seweryn Bialasiewicz
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, Australia
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- ICU and Jameson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
- Nimes University Hospital, University of Montpellier, Nimes, France
| | - Brian M Forde
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
| | - Patrick N A Harris
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- Herston Infectious Disease Institute, Metro North, QLD Health, Herston, QLD, Australia
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Luregn J Schlapbach
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, QLD, Australia
- Department of Pediatric and Neonatal Intensive Care, University Children's Hospital Zurich, Zurich, Switzerland
| | - Lachlan Coin
- Department of Microbiology and Immunology, University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia
- Herston Infectious Disease Institute, Metro North, QLD Health, Herston, QLD, Australia
| | - Adam D Irwin
- UQ Centre for Clinical Research, The University of Queensland, Brisbane, QLD, Australia.
- Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Australia.
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15
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Chai MG, Roberts NA, Dobbins C, Roberts JA, Cotta MO. Factors Influencing Integration and Usability of Model-Informed Precision Dosing Software in the Intensive Care Unit. Appl Clin Inform 2024; 15:388-396. [PMID: 38754464 PMCID: PMC11098592 DOI: 10.1055/s-0044-1786978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Antimicrobial dosing in critically ill patients is challenging and model-informed precision dosing (MIPD) software may be used to optimize dosing in these patients. However, few intensive care units (ICU) currently adopt MIPD software use. OBJECTIVES To determine the usability of MIPD software perceived by ICU clinicians and identify implementation barriers and enablers of software in the ICU. METHODS Clinicians (pharmacists and medical staff) who participated in a wider multicenter study using MIPD software were invited to participate in this mixed-method study. Participants scored the industry validated Post-study System Usability Questionnaire (PSSUQ, assessing software usability) and Technology Acceptance Model 2 (TAM2, assessing factors impacting software acceptance) survey. Semistructured interviews were used to explore survey responses. The framework approach was used to identify factors influencing software usability and integration into the ICU from the survey and interview data. RESULTS Seven of the eight eligible clinicians agreed to participate in the study. The PSSUQ usability scores ranked poorer than the reference norms (2.95 vs. 2.62). The TAM2 survey favorably ranked acceptance in all domains, except image. Qualitatively, key enablers to workflow integration included clear and accessible data entry, visual representation of recommendations, involvement of specialist clinicians, and local governance of software use. Barriers included rigid data entry systems and nonconformity of recommendations to local practices. CONCLUSION Participants scored the MIPD software below the threshold that implies good usability. Factors such as availability of software support by specialist clinicians was important to participants while rigid data entry was found to be a deterrent.
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Affiliation(s)
- Ming G. Chai
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Natasha A. Roberts
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia
| | - Chelsea Dobbins
- School of Electrical Engineering and Computer Science, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A. Roberts
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, Brisbane, Queensland, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nimes University Hospital, University of Montpellier, Nimes, France
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Australia
| | - Menino O. Cotta
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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16
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Van Wynsberge G, Grootaert V, Buyle F, Van Praet J, Colman R, Moors I, Somers A, Veld DHI', De Cock P. Impact of model-informed precision dosing in adults receiving vancomycin via continuous infusion: a randomized, controlled clinical trial. Trials 2024; 25:126. [PMID: 38365814 PMCID: PMC10870500 DOI: 10.1186/s13063-024-07965-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/02/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Vancomycin is a commonly prescribed antibiotic to treat gram-positive infections. The efficacy of vancomycin is known to be directly related to the pharmacokinetic/pharmacodynamic (PK/PD) index of the area under the concentration-time curve (AUC) divided by the minimal inhibitory concentration (MIC) of the pathogen. However, in most countries, steady-state plasma concentrations are used as a surrogate parameter of target AUC/MIC, but this practice has some drawbacks. Hence, direct AUC-guided monitoring of vancomycin using model-informed precision dosing (MIPD) tools has been proposed for earlier attainment of target concentrations and reducing vancomycin-related nephrotoxicity. However, solid scientific evidence for these benefits in clinical practice is still lacking. This randomized controlled trial (RCT) aims to investigate the clinical utility of MIPD dosing of vancomycin administered via continuous infusion in hospitalized adults. METHODS Participants from 11 wards at two Belgian hospitals are randomly allocated to the intervention group or the standard-of-care comparator group. In the intervention group, clinical pharmacists perform dose calculations using CE-labeled MIPD software and target an AUC24h of 400 to 600 mg × h/L, whereas patients in the comparator group receive standard-of-care dosing and monitoring according to the institutional guidelines. The primary endpoint is the proportion of patients reaching the target AUC24h/MIC of 400-600 between 48 and 72 h after start of vancomycin treatment. Secondary endpoints are the proportion of patients with (worsening) acute kidney injury (AKI) during and until 48 h after stop of vancomycin treatment, the proportion of patients reaching target AUC24h/MIC of 400-600 between 72 and 96 h after start of vancomycin treatment, and the proportion of time within the target AUC24h/MIC of 400-600. DISCUSSION This trial will clarify the propagated benefits and provide new insights into how to optimally monitor vancomycin treatment. TRIAL REGISTRATION EudraCT number: 2021-003670-31. Registered June 28, 2021. CLINICALTRIALS gov identifier: NCT05535075. Registered September 10, 2022. Protocol version 3, protocol date: April 21, 2023.
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Affiliation(s)
| | - Veerle Grootaert
- Department of Pharmacy, General Hospital Sint-Jan Bruges, Bruges, Belgium
| | - Franky Buyle
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Jens Van Praet
- Department of Nephrology and Infectious Diseases, General Hospital Sint-Jan Bruges, Bruges, Belgium
| | - Roos Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Ine Moors
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Diana Huis In 't Veld
- Department of General Internal Medicine and Infectious Diseases, Ghent University Hospital, Ghent, Belgium
| | - Pieter De Cock
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium.
- Department of Basic and Applied Medical Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
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17
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Knight JM, Iso T, Perez KK, Swan JT, Janak CE, Ikwuagwu JO, Musick WL. Risk of Acute Kidney Injury Based on Vancomycin Target Trough Attainment Strategy: Area-Under-the-Curve-Guided Bayesian Software, Nomogram, or Trough-Guided Dosing. Ann Pharmacother 2024; 58:110-117. [PMID: 37144736 DOI: 10.1177/10600280231171373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Guidelines support area-under-the-curve (AUC) monitoring for vancomycin dosing which may lower overall doses and reduce acute kidney injury (AKI). OBJECTIVE The aim of this study was to compare incidence of AKI across 3 vancomycin dosing modalities: AUC-targeted Bayesian pharmacokinetic software, AUC-targeted empiric dosing nomogram, and trough-guided dosing using clinical pharmacists' judgment. METHODS This retrospective study included adult patients with a pharmacy dosing consult who received ≥1 dose of vancomycin and ≥1 serum vancomycin level documented between January 1, 2018, and December 31, 2019. Patients with baseline serum creatinine ≥2 mg/dL, weight ≥100 kg, receiving renal replacement therapy, AKI prior to vancomycin therapy, or vancomycin ordered only for surgical prophylaxis were excluded. The primary analysis was incidence of AKI adjusted for baseline serum creatinine, age, and intensive care unit admission. A secondary outcome was adjusted incidence of an abnormal trough value (<10 or >20 μg/mL). RESULTS The study included 3459 encounters. Incidence of AKI was 21% for Bayesian software (n = 659), 22% for the nomogram (n = 303), and 32% for trough-guided dosing (n = 2497). Compared with trough-guided dosing, incidence of AKI was lower in the Bayesian (adjusted odds ratio [OR] = 0.72, 95% confidence interval [CI]: 0.58-0.89) and the nomogram (adjusted OR = 0.71, 95% CI: 0.53-0.95) groups. Compared with trough-guided dosing, abnormal trough values were less common in the Bayesian group (adjusted OR = 0.83, 95% CI: 0.69-0.98). CONCLUSION AND RELEVANCE Study results suggest that use of AUC-guided Bayesian software reduces the incidence of AKI and abnormal trough values compared with trough-guided dosing.
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Affiliation(s)
| | - Tomona Iso
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, Houston, TX, USA
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA, USA
| | | | - Joshua T Swan
- Department of Pharmacy, Houston Methodist, Houston, TX, USA
- Department of Surgery, Houston Methodist, Houston, TX, USA
- Center for Outcomes Research, Houston Methodist, Houston, TX, USA
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18
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Gilliam D, Acosta D, Carvour ML, Walraven C. Retrospective review of intermittent and continuous infusion vancomycin for methicillin-resistant Staphylococcus aureus bacteremia. Eur J Clin Pharmacol 2024; 80:75-81. [PMID: 37897529 DOI: 10.1007/s00228-023-03585-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/16/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE Vancomycin is commonly administered as an intermittent infusion (IIV), although vancomycin's stability at room temperature permits administration continuously over 24 h (CIV). At our institution, CIV has been the preferred infusion method for over 20 years due to ease of administration and simplicity of therapeutic drug monitoring. The purpose of this study was to examine the outcomes associated with IIV compared to CIV. METHODS This was a retrospective study of patients who received vancomycin for MRSA bacteremia. The primary outcomes were the time to therapeutic goal and frequency of adverse drug reactions on IIV compared to CIV. Secondary outcomes evaluated all-cause readmission, relapse, and mortality 30 days after completion of therapy. RESULTS Sixty-three patients were included. Significantly fewer patients were able to achieve a therapeutic goal on IIV compared to CIV (52.4% vs. 82.5%, p < 0.01). Patients on IIV took 3.6 days, on average, to reach the target goal, compared to 1.9 days when patients were switched to CIV (95% confidence interval, 0.48-3.04, p < 0.01). Six patients experienced adverse events on IIV, and 15 patients experienced adverse events on CIV (IIV 9.5%, CIV 23.8%, p = 0.035). One patient experienced relapse of infection, and six patients (9.5%) were readmitted 30 days after completion of therapy. There were no deaths in the cohort. CONCLUSION For MRSA bacteremia, CIV enabled patients to achieve the AUC/MIC goal significantly faster than when patients received IIV. Furthermore, patients who were unable to achieve a therapeutic trough on IIV became therapeutic once switched to CIV.
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Affiliation(s)
- Diari Gilliam
- Department of Pharmacy, University of New Mexico Hospitals, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA.
| | - Dominic Acosta
- Department of Pharmacy, Presbyterian Healthcare Services, Albuquerque, NM, 87106, USA
| | - Martha L Carvour
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, 52242, USA
| | - Carla Walraven
- Department of Pharmacy, University of New Mexico Hospitals, 2211 Lomas Blvd NE, Albuquerque, NM, 87106, USA
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19
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Hall NM, Brown ML, Edwards WS, Oster RA, Cordell W, Stripling J. Model-Informed Precision Dosing Improves Outcomes in Patients Receiving Vancomycin for Gram-Positive Infections. Open Forum Infect Dis 2024; 11:ofae002. [PMID: 38250202 PMCID: PMC10799298 DOI: 10.1093/ofid/ofae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Background Consensus guidelines for dosing and monitoring of vancomycin recommend collection of 2 serum concentrations to estimate an area under the curve/minimum inhibitory concentration ratio (AUC/MIC). Use of Bayesian software for AUC estimation and model-informed precision dosing (MIPD) enables pre-steady state therapeutic drug monitoring using a single serum concentration; however, data supporting this approach are limited. Methods Adult patients with culture-proven gram-positive infections treated with vancomycin ≥72 hours receiving either trough-guided or AUC-guided therapy were included in this retrospective study. AUC-guided therapy was provided using MIPD and single-concentration monitoring. Treatment success, vancomycin-associated acute kidney injury (VA-AKI), and inpatient mortality were compared using a desirability of outcome ranking analysis. The most desirable outcome was survival with treatment success and no VA-AKI, and the least desirable outcome was death. Results The study population (N = 300) was comprised of an equal number of patients receiving AUC-guided or trough-guided therapy. More patients experienced the most desirable outcome in the AUC-guided group compared to the trough-guided group (58.7% vs 46.7%, P = .037). Rates of VA-AKI were lower (21.3% vs 32.0%, P = .037) and median hospital length of stay was shorter (10 days [interquartile range {IQR}, 8-20] vs 12 days [IQR, 8-25]; P = .025) among patients receiving AUC-guided therapy. Conclusions AUC-guided vancomycin therapy using MIPD and single-concentration monitoring improved outcomes in patients with culture-proven gram-positive infections. Safety was improved with reduced incidence of VA-AKI, and no concerns for reduced efficacy were observed. Moreover, MIPD allowed for earlier assessment of AUC target attainment and greater flexibility in the collection of serum vancomycin concentrations.
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Affiliation(s)
- Nicole M Hall
- Department of Pharmacy, UAB Hospital, Birmingham, Alabama, USA
| | - Matthew L Brown
- Department of Pharmacy, UAB Hospital, Birmingham, Alabama, USA
| | - W Seth Edwards
- Department of Pharmacy, UAB Hospital, Birmingham, Alabama, USA
| | - Robert A Oster
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Will Cordell
- Department of Pharmacy, The University of Kansas Health System, Kansas City, Kansas, USA
| | - Joshua Stripling
- Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
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20
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Tyler Pitcock C, Schadler A, Burgess DS, Burgess DR, Cotner SE, Van Hoose J, Gregory ER, Wallace KL. Association of vancomycin-induced acute kidney injury with trough versus AUC monitoring in patients receiving extended durations of therapy. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e225. [PMID: 38156206 PMCID: PMC10753493 DOI: 10.1017/ash.2023.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/14/2023] [Accepted: 10/16/2023] [Indexed: 12/30/2023]
Abstract
Objective Vancomycin therapy is associated with an increased risk of acute kidney injury (AKI). Previous studies suggest that area under the curve (AUC) monitoring reduces the risk of AKI, but literature is lacking to support this in patients receiving longer durations of vancomycin therapy. Design Retrospective cohort study. Method Patients ≥18 years old, admitted between August 2015 and July 2017 or October 2017 and September 2019, and received at least 14 days of intravenous (IV) vancomycin therapy were included in the study. Our primary outcome was the incidence of AKI between trough monitoring and AUC monitoring groups using Kidney Disease Improving Global Outcomes criteria. Secondary outcomes included inpatient mortality, median inpatient length of stay, and median intensive care unit length of stay. Results Overall, 582 patients were included in the study, with 318 patients included in the trough monitoring group and 264 included in the AUC monitoring group. The median duration of vancomycin therapy was 23 days (interquartile range, 16-39). Patients within the trough monitoring group had a higher incidence of AKI compared to the AUC monitoring group (45.6% vs 28.4%, p < 0.001). Furthermore, logistic regression analysis showed that AUC monitoring was associated with a 54% lower incidence of AKI (OR 0.46, 95% CI [0.31-0.69]). All-cause inpatient mortality was numerically higher in the trough monitoring group (12.9% vs 8.3%, p = 0.078). Conclusions In patients who received at least 14 days of IV vancomycin therapy, AUC monitoring was associated with a lower incidence of AKI.
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Affiliation(s)
- C. Tyler Pitcock
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Aric Schadler
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Department of Pediatrics, Kentucky Children’s Hospital, Lexington, KY, USA
| | - David S. Burgess
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Donna R. Burgess
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Sarah E. Cotner
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Jeremy Van Hoose
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Eric R. Gregory
- Department of Pharmacy Services, The University of Kansas Health System, Kansas City, KS, USA
| | - Katie L. Wallace
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
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21
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Nolan J, McCarthy K, Farkas A, Avent ML. Feasibility of individualised patient modelling for continuous vancomycin infusions in outpatient antimicrobial therapy, a retrospective study. Int J Clin Pharm 2023; 45:1444-1451. [PMID: 37532840 DOI: 10.1007/s11096-023-01618-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 06/24/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter for dosing vancomycin continuous infusion in methicillin-resistant Staphylococcus aureus (MRSA) infection. Individualised pharmacokinetic-pharmacodynamic (PK/PD) calculation of AUC24 may better represent therapeutic dosing than current Therapeutic Drug Monitoring (TDM) practices, targeting a Steady State Concentration of 15-25 mg/L. AIM To compare real world TDM practice to theoretical, individualised, PK/PD target parameters utilising Bayesian predictions to steady state concentrations (Css) for outpatients on continuous vancomycin infusions. METHOD A retrospective single centre study was conducted at a tertiary hospital on adult patients, enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program, receiving vancomycin infusions for MRSA infection. Retrospective Bayesian dosing was modelled to target PK/PD parameters and compared to real world data. RESULTS Fifteen patients were evaluated with 53% (8/15) achieved target CSS during hospitalisation, and 83% (13/15) as outpatient. Median Bayesian AUC/MIC was 613 mg.h/L with CSS 25 mg/L. Patients suffering an Acute Kidney Injury (33%) had higher AUC0-24/MIC values. Retrospective Bayesian modelling demonstrated on median 250 mg/24 h lower doses than that administered was required (R2 = 0.81) which achieved AUC24/MIC median 444.8 (range 405-460) mg.h/L and CSS 18.8 (range 16.8-20.4) mg/L. CONCLUSION Bayesian modelling could assist in obtaining more timely target parameters at lower doses for patients receiving continuous vancomycin infusion as part of an OPAT program, which may beget fewer adverse effects. Utilisation of personalised predictive modelling may optimise vancomycin prescribing, achieving earlier target concentrations as compared to empiric dosing regimens.
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Affiliation(s)
- J Nolan
- The Royal Brisbane and Women's Hospital, Herston, Australia.
- School of Medicine, University of Queensland, 4029, Herston, Australia.
| | - K McCarthy
- The Royal Brisbane and Women's Hospital, Herston, Australia
- School of Medicine, University of Queensland, 4029, Herston, Australia
| | - A Farkas
- Mount Sinai West Hospital, New York, USA
- Optimum Dosing Strategies, Bloomingdale, New York, USA
| | - M L Avent
- The Royal Brisbane and Women's Hospital, Herston, Australia
- Queensland Statewide Antimicrobial Stewardship Program, University of Queensland Centre for Clinical Research, Herston, Australia
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22
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Garreau R, Pham TT, Bourguignon L, Millet A, Parant F, Bussy D, Desevre M, Franchi V, Ferry T, Goutelle S. Daptomycin Exposure as a Risk Factor for Daptomycin-Induced Eosinophilic Pneumonia and Muscular Toxicity. Clin Infect Dis 2023; 77:1372-1380. [PMID: 37467019 DOI: 10.1093/cid/ciad386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND High-dose daptomycin is increasingly used in patients with bone and joint infection (BJI). This raises concerns about a higher risk of adverse events (AEs), including daptomycin-induced eosinophilic pneumonia (DIEP) and myotoxicity. We aimed to examine pharmacokinetic and other potential determinants of DIEP and myotoxicity in patients with BJI receiving daptomycin. METHODS All patients receiving daptomycin for BJI were identified in a prospective cohort study. Cases were matched at a 1:3 ratio, with controls randomly selected from the same cohort. Bayesian estimation of the daptomycin daily area under the concentration-time curve over 24 hours (AUC24h) was performed with the Monolix software based on therapeutic drug monitoring (TDM) data. Demographic and biological data were also collected. Risk factors of AEs were analyzed using Cox proportional hazards model. RESULTS From 1130 patients followed over 7 years, 9 with DIEP, 26 with myotoxicity, and 106 controls were included in the final analysis. Daptomycin AUC24h, C-reactive protein, and serum protein levels were associated with the risk of AEs. The adjusted hazard ratio of DIEP or myotoxicity was 3.1 (95% confidence interval [CI], 1.48-6.5; P < .001) for daptomycin AUC24h > 939 mg/h/L, 9.8 (95% CI, 3.94-24.5; P < .001) for C-reactive protein > 21.6 mg/L, and 2.4 (95% CI, 1.02-5.65; P = .04) for serum protein <72 g/L. CONCLUSIONS We identified common determinants of DIEP and myotoxicity in patients with BJI. Because the risk of AEs was associated with daptomycin exposure, daptomycin TDM and model-informed precision dosing may help optimize the efficacy and safety of daptomycin treatment in this setting. A target AUC24h range of 666 to 939 mg/h/L is suggested.
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Affiliation(s)
- Romain Garreau
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
- LBBE-Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Université Lyon 1, Villeurbanne, France
| | - Truong-Thanh Pham
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France
| | - Laurent Bourguignon
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
- LBBE-Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Université Lyon 1, Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Univ Lyon, Université Lyon 1, ISPB, Lyon, France
| | - Aurélien Millet
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie -Toxicologie, Lyon, France
| | - François Parant
- Hospices Civils de Lyon, Groupement Hospitalier Sud, Service de Biochimie et Biologie Moléculaire, UM Pharmacologie -Toxicologie, Lyon, France
| | - David Bussy
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France
| | - Marine Desevre
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France
| | - Victor Franchi
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France
| | - Tristan Ferry
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Hôpital de la Croix-Rousse, Service des Maladies Infectieuses et Tropicales, Centre de Référence pour la prise en charge des Infections Ostéo-Articulaires complexes (CRIOAc Lyon), Lyon, France
- Facultés de Médecine et de Pharmacie de Lyon, Univ Lyon, Université Lyon 1, ISPB, Lyon, France
- CIRI-Centre International de Recherche en Infectiologie, Inserm, U1111, Université́ Claude Bernard Lyon 1, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Univ Lyon, Lyon, France
| | - Sylvain Goutelle
- Hospices Civils de Lyon, Groupement Hospitalier Nord, Service de Pharmacie, Lyon, France
- LBBE-Laboratoire de Biométrie et Biologie Evolutive, CNRS, UMR 5558, Université Lyon 1, Villeurbanne, France
- Facultés de Médecine et de Pharmacie de Lyon, Univ Lyon, Université Lyon 1, ISPB, Lyon, France
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Oda K, Yamada T, Matsumoto K, Hanai Y, Ueda T, Samura M, Shigemi A, Jono H, Saito H, Kimura T. Model-informed precision dosing of vancomycin for rapid achievement of target area under the concentration-time curve: A simulation study. Clin Transl Sci 2023; 16:2265-2275. [PMID: 37718491 PMCID: PMC10651648 DOI: 10.1111/cts.13626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/19/2023] Open
Abstract
In this study, we aimed to evaluate limited sampling strategies for achieving the therapeutic ranges of the area under the concentration-time curve (AUC) of vancomycin on the first and second day (AUC0-24 , AUC24-48 , respectively) of therapy. A virtual population of 1000 individuals was created using a population pharmacokinetic (PopPK) model, which was validated and incorporated into our model-informed precision dosing tool. The results were evaluated using six additional PopPK models selected based on a study design of prospective or retrospective data collection with sufficient concentrations. Bayesian forecasting was performed to evaluate the probability of achieving the therapeutic range of AUC, defined as a ratio of estimated/reference AUC within 0.8-1.2. The Bayesian posterior probability of achieving the AUC24-48 range increased from 51.3% (a priori probability) to 77.5% after using two-point sampling at the trough and peak on the first day. Sampling on the first day also yielded a higher Bayesian posterior probability (86.1%) of achieving the AUC0-24 range compared to the a priori probability of 60.1%. The Bayesian posterior probability of achieving the AUC at steady-state (AUCSS ) range by sampling on the first or second day decreased with decreased kidney function. We demonstrated that second-day trough and peak sampling provided accurate AUC24-48 , and first-day sampling may assist in rapidly achieving therapeutic AUC24-48 , although the AUCSS should be re-estimated in patients with reduced kidney function owing to its unreliable predictive performance.
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Affiliation(s)
- Kazutaka Oda
- Department of PharmacyKumamoto University HospitalKumamotoJapan
- Department of Infection ControlKumamoto University HospitalKumamotoJapan
| | - Tomoyuki Yamada
- Department of PharmacyOsaka Medical and Pharmaceutical University HospitalOsakaJapan
| | - Kazuaki Matsumoto
- Division of PharmacodynamicsKeio University Faculty of PharmacyTokyoJapan
| | - Yuki Hanai
- Department of Clinical Pharmacy, Faculty of Pharmaceutical SciencesToho UniversityChibaJapan
| | - Takashi Ueda
- Department of Infection Control and PreventionHyogo College of MedicineNishinomiyaHyogoJapan
| | - Masaru Samura
- Department of PharmacyYokohama General HospitalYokohamaKanagawaJapan
| | - Akari Shigemi
- Department of PharmacyKagoshima University HospitalKagoshima CityKagoshimaJapan
| | - Hirofumi Jono
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Hideyuki Saito
- Department of PharmacyKumamoto University HospitalKumamotoJapan
| | - Toshimi Kimura
- Department of PharmacyJuntendo University HospitalTokyoJapan
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24
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Kalın G, Alp E, Chouaikhi A, Roger C. Antimicrobial Multidrug Resistance: Clinical Implications for Infection Management in Critically Ill Patients. Microorganisms 2023; 11:2575. [PMID: 37894233 PMCID: PMC10609422 DOI: 10.3390/microorganisms11102575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/05/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
The increasing incidence of antimicrobial resistance (AMR) worldwide represents a serious threat in the management of sepsis. Due to resistance to the most common antimicrobials prescribed, multidrug-resistant (MDR) pathogens have been associated with delays in adequate antimicrobial therapy leading to significant increases in mortality, along with prolonged hospital length of stay (LOS) and increases in healthcare costs. In response to MDR infections and the delay of microbiological results, broad-spectrum antibiotics are frequently used in empirical antimicrobial therapy. This can contribute to the overuse and misuse of antibiotics, further promoting the development of resistance. Multiple measures have been suggested to combat AMR. This review will focus on describing the epidemiology and trends concerning MDR pathogens. Additionally, it will explore the crucial aspects of identifying patients susceptible to MDR infections and optimizing antimicrobial drug dosing, which are both pivotal considerations in the fight against AMR. Expert commentary: The increasing AMR in ICUs worldwide makes the empirical antibiotic therapy challenging in septic patients. An AMR surveillance program together with improvements in MDR identification based on patient risk stratification and molecular rapid diagnostic tools may further help tailoring antimicrobial therapies and avoid unnecessary broad-spectrum antibiotics. Continuous infusions of antibiotics, therapeutic drug monitoring (TDM)-based dosing regimens and combination therapy may contribute to optimizing antimicrobial therapy and limiting the emergence of resistance.
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Affiliation(s)
- Gamze Kalın
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Erciyes University, Kayseri 38280, Türkiye
| | - Emine Alp
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ankara Yıldırım Beyazıt University, Ankara 06760, Türkiye;
| | - Arthur Chouaikhi
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
| | - Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 9, 30029 Nîmes, France;
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, Chemin du Carreau de Lanes, 30029 Nîmes, France
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25
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Frymoyer A, Schwenk HT, Brockmeyer JM, Bio L. Impact of model-informed precision dosing on achievement of vancomycin exposure targets in pediatric patients with cystic fibrosis. Pharmacotherapy 2023; 43:1007-1014. [PMID: 37401162 DOI: 10.1002/phar.2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Vancomycin is commonly used to treat acute pulmonary exacerbations in pediatric patients with cystic fibrosis (CF) and a history of methicillin-resistant Staphylococcus aureus. Optimizing vancomycin exposure during therapy is essential and area under-the-curve (AUC)-guided dosing is now recommended. Model-informed precision dosing (MIPD) utilizing Bayesian forecasting is a powerful approach that can support AUC-guided dose individualization. The objective of the current study was to examine the impact of implementing an AUC-guided dose individualization approach supported via a MIPD clinical decision support (CDS) tool on vancomycin exposure, target attainment rate, and safety in pediatric patients with CF treated with vancomycin during clinical care. METHODS A retrospective chart review was performed in patients with CF at a single children's hospital comparing pre- and post-implementation of a MIPD approach for vancomycin supported by a cloud-based, CDS tool integrated into the electronic health record (EHR). In the pre-MIPD period, vancomycin starting doses of 60 mg/kg/day (<13 years) or 45 mg/kg/day (≥13 years) were used. Dose adjustment was guided by therapeutic drug monitoring (TDM) with a target trough 10-20 mg/L. In the post-MIPD period, starting dose and dose adjustment were based on the MIPD CDS tool predictions with a target 24 h AUC (AUC24 ) 400-600 mg*h/L. Exposure and target achievement rates were retrospectively calculated and compared. Rates of acute kidney injury (AKI) were also compared. RESULTS Overall, 23 patient courses were included in the pre-MIPD period and 21 patient courses in the post-MIPD period. In the post-MIPD period, an individualized MIPD starting dose resulted in 71% of patients achieving target AUC24 compared to 39% in the pre-MIPD period (p < 0.05). After the first TDM and dose adjustment, target AUC24 achievement was also higher post-MIPD versus pre-MIPD (86% vs. 57%; p < 0.05). AKI rates were low and similar between periods (pre-MIPD 8.7% vs. post-MIPD 9.5%; p = 0.9). CONCLUSION An MIPD approach implemented within a cloud-based, EHR-integrated CDS tool safely supported vancomycin AUC-guided dosing and resulted in high rates of target achievement.
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Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Hayden T Schwenk
- Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Jake M Brockmeyer
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Laura Bio
- Department of Pharmacy, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
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26
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Williams P, Cotta MO, Abdul-Aziz MH, Wilks K, Farkas A, Roberts JA. In silico Evaluation of a Vancomycin Dosing Guideline Among Adults with Serious Infections. Ther Drug Monit 2023; 45:631-636. [PMID: 37199397 DOI: 10.1097/ftd.0000000000001102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND This study aimed to compare the achievement of pharmacokinetic-pharmacodynamic (PK-PD) exposure targets for vancomycin using a newly developed dosing guideline with product-information-based dosing in the treatment of adult patients with serious infections. METHODS In silico product-information- and guideline-based dosing simulations for vancomycin were performed across a range of doses and patient characteristics, including body weight, age, and renal function at 36-48 and 96 hours, using a pharmacokinetic model derived from a seriously ill patient population. The median simulated concentration and area under the 24-hour concentration-time curve (AUC 0-24 ) were used to measure predefined therapeutic, subtherapeutic, and toxicity PK-PD targets. RESULTS Ninety-six dosing simulations were performed. The pooled median trough concentration target with guideline-based dosing at 36 and 96 hours was achieved in 27.1% (13/48) and 8.3% (7/48) of simulations, respectively. The pooled median AUC 0-24 /minimum inhibitory concentration ratio with guideline-based dosing at 48 and 96 hours was attained in 39.6% (19/48) and 27.1% (13/48) of simulations, respectively. Guideline-based dosing simulations yielded improved trough target attainment compared with product-information-based dosing at 36 hours and significantly less subtherapeutic drug exposure. The toxicity threshold was exceeded in 52.1% (25/48) and 0% (0/48) for guideline- and product-information-information-based dosing, respectively ( P < 0.001). CONCLUSIONS A Critical care vancomycin dosing guideline appeared slightly more effective than standard dosing, as per product information, in achieving PK-PD exposure associated with an increased likelihood of effectiveness. In addition, this guideline significantly reduced the risk of subtherapeutic exposure. The risk of exceeding toxicity thresholds, however, was greater with the guideline, and further investigation is suggested to improve dosing accuracy and sensitivity.
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Affiliation(s)
- Paul Williams
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
- School of Public Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Andras Farkas
- Department of Pharmacy, Mount Sinai West, New York, New York
- Optimum Dosing Strategies, Bloomingdale, New Jersey
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute (HeIDI), Metro North Health, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes France
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27
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Baiocco GG, Greiner S, Rosa MB, Flores CD, Barros HMT. Impact of implementing a vancomycin protocol to reduce kidney toxicity: A comparative study. Front Pharmacol 2023; 14:1154573. [PMID: 37841919 PMCID: PMC10569023 DOI: 10.3389/fphar.2023.1154573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction: Vancomycin is a frequently used antibiotic for treating severe infections caused by multidrug-resistant, Gram-positive pathogens. To ensure its effectiveness and minimize the risk of nephrotoxicity, safe administration and dose monitoring are crucial. Understanding the impact of vancomycin serum levels on clinical outcomes is of paramount importance, necessitating improved knowledge on its use, dose monitoring, nephrotoxicity, and safe administration. Objective: This study aimed to evaluate the incidence of acute kidney injury (AKI) in patients receiving vancomycin before and after the implementation of an institutional protocol for vancomycin administration in a public tertiary hospital in southern Brazil. Materials and methods: A cross-sectional study design was employed, analyzing data from the electronic medical records of 422 patients who received vancomycin. The patient population was divided into two independent cohorts: those treated in 2016 (pre-protocol) and those treated in 2018 (post-protocol), following the implementation of the institutional vancomycin administration protocol. Results: The study included 211 patients in each year of assessment. Patients from both cohorts had a Charlson Comorbidity Index (CCI) score of 4. The post-protocol cohort consisted of older individuals, with a mean age of 62.8 years. In addition, patients in the post-protocol year had higher baseline creatinine levels, higher rates of intensive care unit (ICU) hospitalization, and increased use of vasopressors. In the pre-protocol year, patients received vancomycin therapy for a longer duration. When comparing the incidence of AKI between the two groups, an intervention study revealed rates of 38.4% in group 1 and 20.9% in group 2, indicating a significant reduction (p < 0.001) in the post-protocol group. A logistic regression model was developed to predict AKI, incorporating variables that demonstrated significance (p ≤ 0.250) in bivariate analysis and those recognized in the literature as important factors for AKI, such as the duration of therapy, vancomycin serum level, and ICU hospitalization. The logistic regression classification performance was assessed using a receiver operating characteristic (ROC) curve, yielding an area under the curve of 0.764, signifying acceptable discrimination of the regression model. Conclusion: Implementation of the institutional protocol for vancomycin administration resulted in a significant and cost-effective impact, ensuring appropriate therapeutic dosing, reducing adverse events (e.g., nephrotoxicity), and improving clinical outcomes for patients in the study population.
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Affiliation(s)
- Graziella Gasparotto Baiocco
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Stephanie Greiner
- Gestão de Risco Assistencial do Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | - Mário Borges Rosa
- Presidente do Instituto para Práticas Seguras no Uso de Medicamentos, ISMP, Belo Horizonte, Brazil
| | - Cecília Dias Flores
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Helena M. T. Barros
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
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28
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Zhai X, Tian Y, Zhao K, Liu Z, Chang Y. Effectiveness of a low trough serum concentration of vancomycin on acute kidney injury in infants and toddlers in the paediatric intensive care unit. Eur J Hosp Pharm 2023:ejhpharm-2023-003902. [PMID: 37758318 DOI: 10.1136/ejhpharm-2023-003902] [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: 07/05/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE This study aimed to assess the effectiveness of a low trough serum concentration of vancomycin on acute kidney injury in infants and toddlers in the paediatric intensive care unit (PICU). METHODS A retrospective cohort study was performed of 126 infants and toddlers (aged between 29 days and 3 years) from the PICU of a tertiary care hospital who were administered intravenous vancomycin between January 2019 and December 2022. Information about their demographic factors, duration of PICU stay, time of administration and trough levels of vancomycin were retrieved. Descriptive statistics were used for demographic factors and multivariable logistic regression analyses were conducted to assess the determining factors. RESULTS Based on the trough concentration of vancomycin, the participants were divided into three groups as follows: 4-5 mg/L, 5-15 mg/L and >15 mg/L. The serum vancomycin concentration was significantly related to body weight, albumin, cystatin C, urea nitrogen in serum, serum creatinine and creatinine clearance (p<0.05) in these patients. Multivariate analysis showed that body weight, albumin, cystatin C, urea nitrogen in serum and creatinine clearance were independent contributors to the trough vancomycin concentration. There was no difference in the effectiveness of different trough concentrations on patients (p=0.241). The cumulative incidence of acute kidney injury was highest in the group with a trough concentration of vancomycin >15 mg/L (p<0.01). CONCLUSIONS Patients with a vancomycin trough concentration of 4-5 mg/L in the PICU had a high cure rate (79.4%) and a low incidence of acute kidney injury (HR 18.3, 95% CI 5.135 to 87.621; p<0.001). Therefore, the serum trough concentration should be considered but it should also be combined with the treatment effect to achieve individualised administration for the clinical application of vancomycin.
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Affiliation(s)
- Xin Zhai
- Department of Pharmacy, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yun Tian
- Department of Clinical Pharmacy, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, China
| | - Kai Zhao
- Department of Pharmacy, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Zhenguo Liu
- Department of Pharmacy, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Ying Chang
- Department of Pharmacy, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
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Alnezary FS, Almutairi MS, Gonzales-Luna AJ, Thabit AK. The Significance of Bayesian Pharmacokinetics in Dosing for Critically Ill Patients: A Primer for Clinicians Using Vancomycin as an Example. Antibiotics (Basel) 2023; 12:1441. [PMID: 37760737 PMCID: PMC10525617 DOI: 10.3390/antibiotics12091441] [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: 08/14/2023] [Revised: 09/06/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
Antibiotic use is becoming increasingly challenging with the emergence of multidrug-resistant organisms. Pharmacokinetic (PK) alterations result from complex pathophysiologic changes in some patient populations, particularly those with critical illness. Therefore, antibiotic dose individualization in such populations is warranted. Recently, there have been advances in dose optimization strategies to improve the utilization of existing antibiotics. Bayesian-based dosing is one of the novel approaches that could help clinicians achieve target concentrations in a greater percentage of their patients earlier during therapy. This review summarizes the advantages and disadvantages of current approaches to antibiotic dosing, with a focus on critically ill patients, and discusses the use of Bayesian methods to optimize vancomycin dosing. The Bayesian method of antibiotic dosing was developed to provide more precise predictions of drug concentrations and target achievement early in therapy. It has benefits such as the incorporation of personalized PK/PD parameters, improved predictive abilities, and improved patient outcomes. Recent vancomycin dosing guidelines emphasize the importance of using the Bayesian method. The Bayesian method is able to achieve appropriate antibiotic dosing prior to the patient reaching the steady state, allowing the patient to receive the right drug at the right dose earlier in therapy.
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Affiliation(s)
- Faris S. Alnezary
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Madinah 41477, Saudi Arabia;
| | - Masaad Saeed Almutairi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim 51452, Saudi Arabia
| | - Anne J. Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX 77204, USA;
| | - Abrar K. Thabit
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, 7027 Abdullah Al-Sulaiman Rd, Jeddah 21589, Saudi Arabia;
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Contejean A, Maillard A, Canouï E, Kernéis S, Fantin B, Bouscary D, Parize P, Garcia-Vidal C, Charlier C. Advances in antibacterial treatment of adults with high-risk febrile neutropenia. J Antimicrob Chemother 2023; 78:2109-2120. [PMID: 37259598 DOI: 10.1093/jac/dkad166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND High-risk febrile neutropenia (HR-FN) is a life-threatening complication in patients with haematological malignancies or receiving myelosuppressive chemotherapy. Since the last international guidelines were published over 10 years ago, there have been major advances in the understanding and management of HR-FN, including on antibiotic pharmacokinetics and discontinuation/de-escalation strategies. OBJECTIVES Summarizing major advances in the field of antibacterial therapy in patients with HR-FN: empirical therapy, pharmacokinetics of antibiotics and antibiotic stewardship. SOURCES Narrative review based on literature review from PubMed. We focused on studies published between 2010 and 2023 about the pharmacokinetics of antimicrobials, management of antimicrobial administration, and discontinuation/de-escalation strategies. We did not address antimicrobial prophylaxis, viral or fungal infections. CONTENT Several high-quality publications have highlighted important modifications of antibiotic pharmacokinetics in HR-FN, with standard dosages exposing patients to underdosing. These recent clinical and population pharmacokinetics studies help improve management protocols with optimized initial dosing and infusion rules for β-lactams, vancomycin, daptomycin and amikacin; they highlight the potential benefits of therapeutic drug monitoring. A growing body of evidence also shows that antibiotic discontinuation/de-escalation strategies are beneficial for bacterial ecology and patients' outcome. We further discuss methods and limitations for implementation of such protocols in haematology. IMPLICATIONS We highlight recent information about the management of antibacterial therapy in HR-FN that might be considered in updated guidelines for HR-FN management.
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Affiliation(s)
- Adrien Contejean
- Service d'Hématologie, Centre Hospitalier Annecy Genevois, 1 Avenue de l'hôpital, F-74370 Epagny Metz-Tessy, France
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
| | - Alexis Maillard
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Etienne Canouï
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Solen Kernéis
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Équipe de Prévention du Risque Infectieux, AP-HP, Hôpital Bichat, F-75018 Paris, France
- Université Paris Cité, INSERM, IAME, F-75018 Paris, France
| | - Bruno Fantin
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Département de Médecine Interne, AP-HP, Hôpital Beaujon, F-92110, Clichy, France
| | - Didier Bouscary
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- Service d'Hématologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
| | - Perrine Parize
- Service de Maladies Infectieuses, AP-HP, APHP.CUP, Hôpital Necker-Enfants Malades, F-75015 Paris, France
| | - Carolina Garcia-Vidal
- Infectious Diseases Department, Hospital Clínic-IDIBAPS, Barcelona, Spain
- CIBERINF, Madrid, Spain
| | - Caroline Charlier
- Équipe Mobile d'Infectiologie, AP-HP, APHP.CUP, Hôpital Cochin, F-75014 Paris, France
- Université Paris Cité, Faculté de Médecine, F-75006 Paris, France
- National Reference Center Listeriosis WHO Collaborating Center, Institut Pasteur, F-75015 Paris, France
- Biology of Infection Unit, Inserm U1117 Institut Pasteur, F-75015 Paris, France
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Benefield RJ, McDonald J, Newman M, Tritle B, Certain LK. Patient safety outcomes for continuous infusion vancomycin as outpatient parenteral antimicrobial therapy. Pharmacotherapy 2023; 43:894-903. [PMID: 37248438 DOI: 10.1002/phar.2833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Administration of vancomycin as a continuous infusion has been associated with reduced nephrotoxicity. Given limited published experience with continuous infusion vancomycin in outpatient parenteral antimicrobial therapy (OPAT) programs, we reviewed outcomes from our center. METHODS This was a retrospective, single-center study of adult patients receiving vancomycin OPAT as continuous or intermittent infusion for an intended treatment duration of at least 7 days. The primary outcome was time to nephrotoxicity with continuous versus intermittent infusion vancomycin while on OPAT; additional outcomes included time to any vancomycin-associated adverse event, time to 60-day death or readmission, and time to 60-day emergency department encounter. Proportional hazards modeling was used to identify variables independently associated with outcomes, as well as assess the strength of association of continuous infusion with each outcome. RESULTS Four-hundred ninety-two patients were included: 118 treated with continuous and 374 with intermittent vancomycin infusion. Continuous infusion was not associated with lower rates of nephrotoxicity compared to intermittent infusion (adjusted hazard ratio (aHR) 0.72, 95% CI: 0.35-1.50). There were no advantages of continuous over intermittent infusion in the rates of any adverse event (aHR 0.93, 95% CI: 0.56-1.53), 60-day death or readmission (aHR 1.04, 95% CI: 0.68-1.61), or 60-day emergency department encounter (aHR 1.17, 95% CI: 0.68-1.99). Vancomycin area under the concentration-time curve (AUC) at discharge was the only modifiable factor identified that was independently associated with patient safety outcomes. CONCLUSION There was no appreciable benefit of continuous infusion vancomycin on outpatient safety outcomes. AUC-centered dosing approaches warrant further investigation as strategies to improve vancomycin safety in OPAT programs.
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Affiliation(s)
- Russell J Benefield
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Joshua McDonald
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Michael Newman
- Data Sciences Services, University of Utah Health, Salt Lake City, Utah, USA
| | - Brandon Tritle
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Laura K Certain
- Division of Infectious Diseases, University of Utah Health, Salt Lake City, Utah, USA
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Cerenzio J, Truong J. Efficacy and Safety of Vancomycin Bayesian-Estimated Area Under the Curve Versus Trough-Based Dosing. Ann Pharmacother 2023; 57:931-939. [PMID: 36476049 DOI: 10.1177/10600280221141402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Vancomycin guidelines by the Infectious Diseases Society of America and American Society of Health-System Pharmacists endorse Bayesian-software-assisted area under the curve (AUC24h) in their 2020 update. At this time, there are limited clinical data that support its use. OBJECTIVES The purpose of this study is to evaluate the safety benefits and efficacy outcomes of using Bayesian-assisted AUC24h dosing compared to trough dosing. METHODS Hospitalized patients from before February 1, 2020, (preimplementation of AUC24h dosing) and after August 1, 2020, (postimplementation) were reviewed. Patients with confirmed or suspected methicillin-resistant Staphylococcus aureus (MRSA) infection of the lungs, heart, bones, prosthetic joint, or blood receiving vancomycin for at least 72 hours were included. The primary endpoint was the percentage of patients experiencing an acute kidney injury (AKI) in the trough-based group versus those experiencing AKI in the AUC24h group. The composite of all-cause mortality, 30-day readmission, or change in antibiotic therapy due to clinical worsening in patients with confirmed MRSA infections was included as a secondary endpoint. Data were analyzed with statistical testing methods as appropriate. RESULTS There was a significant reduction in AKI between the AUC24h dosing and trough dosing groups (3% vs 12%; P < 0.01). The efficacy for MRSA infections was also similar between groups (11% vs 14%; P = 0.72). CONCLUSION AND RELEVANCE Bayesian-assisted AUC24h dosing was associated with a significant reduction in incidence of AKI when compared to trough-based dosing. There was no difference in the composite efficacy endpoint for patients with confirmed MRSA infection, although the study was not powered for this analysis. These data may provide evidence for more institutions to adopt the Bayesian software to assist in dosing of vancomycin.
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Affiliation(s)
- John Cerenzio
- Department of Pharmacy, The Brooklyn Hospital Center, Brooklyn, NY, USA
| | - James Truong
- Department of Pharmacy, The Brooklyn Hospital Center, Brooklyn, NY, USA
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33
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Jorgensen SCJ, McIntyre M, Curran J, So M. Vancomycin Therapeutic Drug Monitoring: A Cross-Sectional Survey of Canadian Hospitals. Can J Hosp Pharm 2023; 76:203-208. [PMID: 37409147 PMCID: PMC10284285 DOI: 10.4212/cjhp.3337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Background Little is known about the current landscape of vancomycin therapeutic drug monitoring (TDM) in Canadian hospitals, which operate within publicly funded health care systems. Objectives To determine current TDM practices for vancomycin and associated challenges and to gather perceptions about TDM based on area under the concentration-time curve (AUC) in Canadian hospitals. Methods An electronic survey was distributed to hospital pharmacists in spring 2021 through multiple national and provincial antimicrobial stewardship, public health, and pharmacy organizations. The survey gathered data about hospital characteristics, TDM methods, inclusion criteria for patient selection, pharmacokinetic and pharmacodynamic targets, vancomycin susceptibility testing and reporting, and perceived barriers and challenges. Results In total, 120 pharmacists from 10 of the 13 provincial and territorial jurisdictions in Canada, representing 12.5% of Canadian acute care hospitals (n = 962), completed at least 90% of survey questions. The predominant TDM method was trough-based (107/119, 89.9%); another 10.1% of respondents (12/119) reported performing AUC-based TDM (with or without trough-based TDM), and 17.9% (19/106) of those not already using AUC-based TDM were considering implementing it within 1 to 2 years. Among hospitals performing trough-based TDM, 60.5% (66/109) targeted trough levels between 15 and 20 mg/L for serious infections with methicillin-resistant Staphylococcus aureus. One-quarter of the respondents using this method (27/109, 24.8%) agreed that trough-based TDM was of uncertain benefit, and about one-third (33/109, 30.3%) were neutral on this question. Multiple challenges were identified for trough-based TDM, including sub- or supra-therapeutic concentrations and collection of specimens at inappropriate times. Overall, 40.5% (47/116) of respondents agreed that AUC-based TDM was likely safer than trough-based TDM, whereas 23.3% (27/116) agreed that AUC-based TDM was likely more effective. Conclusions This survey represents a first step in developing evidence-based, standardized best practices for vancomycin TDM that are uniquely suited to the Canadian health care system.
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Affiliation(s)
- Sarah C J Jorgensen
- , PharmD, MPH, is with the Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario
| | - Mark McIntyre
- , PharmD, is with the Antimicrobial Stewardship Program, Sinai Health/University Health Network, and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Jennifer Curran
- , PharmD, is with the Antimicrobial Stewardship Program, Sinai Health/University Health Network, and the Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario
| | - Miranda So
- , PharmD, MPH, is with the Antimicrobial Stewardship Program, Sinai Health/University Health Network; the Leslie Dan Faculty of Pharmacy, University of Toronto; and the Toronto General Hospital Research Institute, Toronto, Ontario
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34
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Hanna PE, Wang Q, Strohbehn IA, Moreno D, Harden D, Ouyang T, Katz-Agranov N, Seethapathy H, Reynolds KL, Gupta S, Leaf DE, Sise ME. Medication-Related Adverse Events and Discordancies in Cystatin C-Based vs Serum Creatinine-Based Estimated Glomerular Filtration Rate in Patients With Cancer. JAMA Netw Open 2023; 6:e2321715. [PMID: 37405775 PMCID: PMC10323710 DOI: 10.1001/jamanetworkopen.2023.21715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/19/2023] [Indexed: 07/06/2023] Open
Abstract
Importance Serum creatinine-based estimated glomerular filtration rate (eGFRcr) may overestimate the glomerular filtration rate (GFR) in patients with cancer. Cystatin C-based eGFR (eGFRcys) is an alternative marker of GFR. Objective To determine whether the therapeutic drug levels and adverse events (AEs) associated with renally cleared medications were higher in patients with cancer whose eGFRcys was more than 30% lower than their eGFRcr. Design, Setting, and Participants This cohort study analyzed adult patients with cancer at 2 major academic cancer centers in Boston, Massachusetts. These patients had their creatinine and cystatin C measured on the same day between May 2010 and January 2022. The date of the first simultaneous eGFRcr and eGFRcys measurement was considered to be the baseline date. Exposure The primary exposure was eGFR discordance, defined as an eGFRcys that was more than 30% lower than the eGFRcr. Main Outcomes and Measures The primary outcome was risk of the following medication-related AEs within 90 days of the baseline date: (1) supratherapeutic vancomycin trough level greater than 30 μg/mL, (2) trimethoprim-sulfamethoxazole-related hyperkalemia (>5.5 mEq/L), (3) baclofen toxic effect, and (4) supratherapeutic digoxin level (>2.0 ng/mL). For the secondary outcome, a multivariable Cox proportional hazards regression model was used to compare 30-day survival of those with vs without eGFR discordance. Results A total of 1869 adult patients with cancer (mean [SD] age, 66 [14] years; 948 males [51%]) had simultaneous eGFRcys and eGFRcr measurement. There were 543 patients (29%) with an eGFRcys that was more than 30% lower than their eGFRcr. Patients with an eGFRcys that was more than 30% lower than their eGFRcr were more likely to experience medication-related AEs compared with patients with concordant eGFRs (defined as eGFRcys within 30% of eGFRcr), including vancomycin levels greater than 30 μg/mL (43 of 179 [24%] vs 7 of 77 [9%]; P = .01), trimethoprim-sulfamethoxazole-related hyperkalemia (29 of 129 [22%] vs 11 of 92 [12%]; P = .07), baclofen toxic effects (5 of 19 [26%] vs 0 of 11; P = .19), and supratherapeutic digoxin levels (7 of 24 [29%] vs 0 of 10; P = .08). The adjusted odds ratio for vancomycin levels more than 30 μg/mL was 2.59 (95% CI, 1.08-7.03; P = .04). Patients with an eGFRcys more than 30% lower than their eGFRcr had an increased 30-day mortality (adjusted hazard ratio, 1.98; 95% CI, 1.26-3.11; P = .003). Conclusions and relevance Results of this study suggest that among patients with cancer with simultaneous assessment of eGFRcys and eGFRcr, supratherapeutic drug levels and medication-related AEs occurred more commonly in those with an eGFRcys more than 30% lower than their eGFRcr. Future prospective studies are needed to improve and personalize GFR estimation and medication dosing in patients with cancer.
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Affiliation(s)
- Paul E. Hanna
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Qiyu Wang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Ian A. Strohbehn
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Daiana Moreno
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Destiny Harden
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Tianqi Ouyang
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Nurit Katz-Agranov
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Harish Seethapathy
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Kerry L. Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Meghan E. Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston
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Chang J, Tasellari A, Wagner JL, Scheetz MH. Contemporary pharmacologic treatments of MRSA for hospitalized adults: rationale for vancomycin versus non-vancomycin therapies as first line agents. Expert Rev Anti Infect Ther 2023; 21:1309-1325. [PMID: 37876291 DOI: 10.1080/14787210.2023.2275663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/23/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Methicillin-resistant Staphylococcus aureus (MRSA) remains an important pathogen in the hospital setting and causes significant morbidity and mortality each year. Since the initial discovery over 60 years ago, vancomycin has remained a first-line treatment for many different types of MRSA infections. However, significant concerns related to target attainment and nephrotoxicity have spurred efforts to develop more effective agents in the last two decades. AREAS COVERED Newer anti-MRSA antibiotics that have been approved since 2000 include linezolid, daptomycin, and ceftaroline. As clinical evidence has accumulated, these newer agents have become more frequently used, and some are now recommended as co-first-line options (along with vancomycin) in clinical practice guidelines. For this review, a scoping review of the literature was conducted to support our findings and recommendations. EXPERT OPINION Vancomycin remains an important standard of care for MRSA infections but is limited with respect to nephrotoxicity and rapid target attainment. Newer agents such as linezolid, daptomycin, and ceftaroline have specific indications for treating different types of MRSA infections; however, newer agents also have unique attributes which require consideration during therapy.
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Affiliation(s)
- Jack Chang
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
| | - Ardita Tasellari
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
| | - Jamie L Wagner
- School of Pharmacy, University of Mississippi, Jackson, MS, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Pharmacometrics Center of Excellence, Midwestern University College of Pharmacy, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
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36
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Williams PG, Tabah A, Cotta MO, Sandaradura I, Kanji S, Scheetz MH, Imani S, Elhadi M, Luque-Pardos S, Schellack N, Sanches C, Timsit JF, Xie J, Farkas A, Wilks K, Roberts JA. International survey of antibiotic dosing and monitoring in adult intensive care units. Crit Care 2023; 27:241. [PMID: 37331935 DOI: 10.1186/s13054-023-04527-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/07/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND In recent years, numerous dosing studies have been conducted to optimize therapeutic antibiotic exposures in patients with serious infections. These studies have led to the inclusion of dose optimization recommendations in international clinical practice guidelines. The last international survey describing dosing, administration and monitoring of commonly prescribed antibiotics for critically ill patients was published in 2015 (ADMIN-ICU 2015). This study aimed to describe the evolution of practice since this time. METHODS A cross-sectional international survey distributed through professional societies and networks was used to obtain information on practices used in the dosing, administration and monitoring of vancomycin, piperacillin/tazobactam, meropenem and aminoglycosides. RESULTS A total of 538 respondents (71% physicians and 29% pharmacists) from 409 hospitals in 45 countries completed the survey. Vancomycin was mostly administered as an intermittent infusion, and loading doses were used by 74% of respondents with 25 mg/kg and 20 mg/kg the most favoured doses for intermittent and continuous infusions, respectively. Piperacillin/tazobactam and meropenem were most frequently administered as an extended infusion (42% and 51%, respectively). Therapeutic drug monitoring was undertaken by 90%, 82%, 43%, and 39% of respondents for vancomycin, aminoglycosides, piperacillin/tazobactam, and meropenem, respectively, and was more frequently performed in high-income countries. Respondents rarely used dosing software to guide therapy in clinical practice and was most frequently used with vancomycin (11%). CONCLUSIONS We observed numerous changes in practice since the ADMIN-ICU 2015 survey was conducted. Beta-lactams are more commonly administered as extended infusions, and therapeutic drug monitoring use has increased, which align with emerging evidence.
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Affiliation(s)
- Paul G Williams
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia.
- Pharmacy Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia.
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia
- Intensive Care Unit, Redcliffe Hospital, Redcliffe, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
| | - Menino Osbert Cotta
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Indy Sandaradura
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia
- Institute for Clinical Pathology and Medical Research, New South Wales Health Pathology, Sydney, NSW, Australia
| | - Salmaan Kanji
- The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marc H Scheetz
- Pharmacometric Center of Excellence, Departments of Pharmacy Practice and Pharmacology, College of Pharmacy, Midwestern University, Downers Grove, IL, USA
| | - Sahand Imani
- Nepean Blue Mountains Local Health District, Nepean Hospital, Sydney, NSW, Australia
| | | | - Sònia Luque-Pardos
- Pharmacy Department, Parc de Salut Mar, Barcelona, Spain
- Infectious Pathology and Antimicrobials Research Group (IPAR), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- CIBER of Pharmacy, Saint Clare's Infectious Diseases (CIBERINFEC CB21/13/0002) Institute of Health Carlos III, Madrid, Spain
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Cristina Sanches
- Campus Centro Oeste Dona Lindu, Federal University of Sao João del Rei, Divinópolis, Minas Gerais, Brasil
| | - Jean-Francois Timsit
- Assistance Publique Hôpitaux de Paris - Bichat hospital Medical and infectious diseases ICU (MI2), 75018, Paris, France
- IAME U 1137 Université Paris-Cité Site Bichat, 75018, Paris, France
| | - Jiao Xie
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Andras Farkas
- Optimum Dosing Strategies, Bloomingdale, NJ, USA
- Department of Pharmacy, Saint Clare's Health, Denville, NJ, USA
| | - Kathryn Wilks
- Infectious Diseases Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Jason A Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, QLD, 4029, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Pharmacy Department, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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Cherian JP, Jones GF, Bachina P, Helsel T, Virk Z, Lee JH, Fiawoo S, Salinas A, Dzintars K, O'Shaughnessy E, Gopinath R, Tamma PD, Cosgrove SE, Klein EY. An Electronic Algorithm to Identify Vancomycin-Associated Acute Kidney Injury. Open Forum Infect Dis 2023; 10:ofad264. [PMID: 37383251 PMCID: PMC10296058 DOI: 10.1093/ofid/ofad264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/12/2023] [Indexed: 06/30/2023] Open
Abstract
Background The burden of vancomycin-associated acute kidney injury (V-AKI) is unclear because it is not systematically monitored. The objective of this study was to develop and validate an electronic algorithm to identify cases of V-AKI and to determine its incidence. Methods Adults and children admitted to 1 of 5 health system hospitals from January 2018 to December 2019 who received at least 1 dose of intravenous (IV) vancomycin were included. A subset of charts was reviewed using a V-AKI assessment framework to classify cases as unlikely, possible, or probable events. Based on review, an electronic algorithm was developed and then validated using another subset of charts. Percentage agreement and kappa coefficients were calculated. Sensitivity and specificity were determined at various cutoffs, using chart review as the reference standard. For courses ≥48 hours, the incidence of possible or probable V-AKI events was assessed. Results The algorithm was developed using 494 cases and validated using 200 cases. The percentage agreement between the electronic algorithm and chart review was 92.5% and the weighted kappa was 0.95. The electronic algorithm was 89.7% sensitive and 98.2% specific in detecting possible or probable V-AKI events. For the 11 073 courses of ≥48 hours of vancomycin among 8963 patients, the incidence of possible or probable V-AKI events was 14.0%; the V-AKI incidence rate was 22.8 per 1000 days of IV vancomycin therapy. Conclusions An electronic algorithm demonstrated substantial agreement with chart review and had excellent sensitivity and specificity in detecting possible or probable V-AKI events. The electronic algorithm may be useful for informing future interventions to reduce V-AKI.
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Affiliation(s)
- Jerald P Cherian
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - George F Jones
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Preetham Bachina
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Taylor Helsel
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zunaira Virk
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jae Hyoung Lee
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Suiyini Fiawoo
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alejandra Salinas
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kate Dzintars
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth O'Shaughnessy
- Division of Anti-Infectives, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Ramya Gopinath
- Division of Anti-Infectives, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eili Y Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Patil T, Zysk SN, Akridge ME, McCraven RW, Vasudeva SS. A Quasi-Experimental Evaluation of Single Trough-Based Area Under the Curve Guided Dosing on the Incidence of Vancomycin Associated Nephrotoxicity in Veteran Patients. J Pharm Technol 2023; 39:123-133. [PMID: 37323768 PMCID: PMC10268043 DOI: 10.1177/87551225231172349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Background: Two common dosing strategies for vancomycin are trough-based and area under the curve (AUC)-based dosing. Objective: To compare the incidence of nephrotoxicity in trough-based dosing group with the single trough-based AUC dosing at the Salem VA Medical Center. Methods: This retrospective study included patients who received trough-based dosing of vancomycin between January 1, 2017, and January 1, 2019 (preimplementation group) and AUC-based dosing (postimplementation) between October 1, 2019, and October 1, 2021, at the Salem VA Medical Center. The primary outcome was nephrotoxicity at 96 hours, 7 days, and entire hospital length of stay (LOS). Secondary outcomes included 30-day readmission and all-cause mortality rates, cumulative doses at 24, 48, and 72 hours, and percentage of patients considered at goal (AUC 400-600 or trough between 10 and 20 mg/L). Propensity score (PS) matching was utilized to adjust for confounding. Results: After PS matching 100 patients were included in preimplementation and 95 patients in the postimplementation group. The average study patient was a 68-year-old white male. There was significant reduction in the risk of nephrotoxicity in postimplementation cohort at 96 hours (adjusted (a)HR: 0.28, 95% CI (0.12-0.66); 7 days (aHR: 0.39, 95% CI (0.18-0.85); and entire hospital LOS (aHR: 0.46, 95% CI (0.22-0.95). Secondary outcomes showed no difference between the groups except significantly higher proportion of patients were considered at therapeutic goal in the postimplementation cohort compared with pre-implementation cohort. Conclusion: This hypothesis generating study shows that AUC-based dosing calculated using single trough concentration may result in reduced rate of nephrotoxicity than trough-based dosing.
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Affiliation(s)
- Tanvi Patil
- Department of Pharmacy, Salem Veterans Affairs Medical Center, Salem Veterans Affairs Health Care System, Salem, VA, USA
| | - Stacey N. Zysk
- Department of Pharmacy, Salem Veterans Affairs Medical Center, Salem Veterans Affairs Health Care System, Salem, VA, USA
| | - Meghan E. Akridge
- Department of Pharmacy, Salem Veterans Affairs Medical Center, Salem Veterans Affairs Health Care System, Salem, VA, USA
| | - Rebecca W. McCraven
- Department of Pharmacy, Salem Veterans Affairs Medical Center, Salem Veterans Affairs Health Care System, Salem, VA, USA
| | - Shikha S. Vasudeva
- Department of Infectious Disease, Salem Veterans Affairs Medical Center, Salem Veterans Affairs Health Care System, Salem, VA, USA
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Oda K, Saito H, Jono H. Bayesian prediction-based individualized dosing of anti-methicillin-resistant Staphylococcus aureus treatment: Recent advancements and prospects in therapeutic drug monitoring. Pharmacol Ther 2023; 246:108433. [PMID: 37149156 DOI: 10.1016/j.pharmthera.2023.108433] [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: 12/26/2022] [Revised: 04/19/2023] [Accepted: 05/02/2023] [Indexed: 05/08/2023]
Abstract
As one of the efficient techniques for TDM, the population pharmacokinetic (popPK) model approach for dose individualization has been developed due to the rapidly growing innovative progress in computer technology and has recently been considered as a part of model-informed precision dosing (MIPD). Initial dose individualization and measurement followed by maximum a posteriori (MAP)-Bayesian prediction using a popPK model are the most classical and widely used approach among a class of MIPD strategies. MAP-Bayesian prediction offers the possibility of dose optimization based on measurement even before reaching a pharmacokinetically steady state, such as in an emergency, especially for infectious diseases requiring urgent antimicrobial treatment. As the pharmacokinetic processes in critically ill patients are affected and highly variable due to pathophysiological disturbances, the advantages offered by the popPK model approach make it highly recommended and required for effective and appropriate antimicrobial treatment. In this review, we focus on novel insights and beneficial aspects of the popPK model approach, especially in the treatment of infectious diseases with anti-methicillin-resistant Staphylococcus aureus agents represented by vancomycin, and discuss the recent advancements and prospects in TDM practice.
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Affiliation(s)
- Kazutaka Oda
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan
| | - Hideyuki Saito
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan; Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University; 1-1-1, Honjo, Chuo-ku, Kumamoto, Japan
| | - Hirofumi Jono
- Department of Pharmacy, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, Japan; Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University; 1-1-1, Honjo, Chuo-ku, Kumamoto, Japan.
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40
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Telles JP, Morales R, Yamada CH, Marins TA, D'Amaro Juodinis V, Sztajnbok J, Silva M, Bassetti BR, Albiero J, Tuon FF. Optimization of Antimicrobial Stewardship Programs Using Therapeutic Drug Monitoring and Pharmacokinetics-Pharmacodynamics Protocols: A Cost-Benefit Review. Ther Drug Monit 2023; 45:200-208. [PMID: 36622029 DOI: 10.1097/ftd.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/08/2022] [Indexed: 01/10/2023]
Abstract
PURPOSE Antimicrobial stewardship programs are important for reducing antimicrobial resistance because they can readjust antibiotic prescriptions to local guidelines, switch intravenous to oral administration, and reduce hospitalization times. Pharmacokinetics-pharmacodynamics (PK-PD) empirically based prescriptions and therapeutic drug monitoring (TDM) programs are essential for antimicrobial stewardship, but there is a need to fit protocols according to cost benefits. The cost benefits can be demonstrated by reducing toxicity and hospital stay, decreasing the amount of drug used per day, and preventing relapses in infection. Our aim was to review the data available on whether PK-PD empirically based prescriptions and TDM could improve the cost benefits of an antimicrobial stewardship program to decrease global hospital expenditures. METHODS A narrative review based on PubMed search with the relevant studies of vancomycin, aminoglycosides, beta-lactams, and voriconazole. RESULTS TDM protocols demonstrated important cost benefit for patients treated with vancomycin, aminoglycosides, and voriconazole mainly due to reduce toxicities and decreasing the hospital length of stay. In addition, PK-PD strategies that used infusion modifications to meropenem, piperacillin-tazobactam, ceftazidime, and cefepime, such as extended or continuous infusion, demonstrated important cost benefits, mainly due to reducing daily drug needs and lengths of hospital stays. CONCLUSIONS TDM protocols and PK-PD empirically based prescriptions improve the cost-benefits and decrease the global hospital expenditures.
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Affiliation(s)
- João Paulo Telles
- - AC Camargo Cancer Center, Infectious Diseases Department, São Paulo
- - Laboratory of Emerging Infectious Diseases, Pontifical Catholic University of Paraná, Curitiba
| | - Ronaldo Morales
- - Clinical Pharmacokinetics Center, School of Pharmaceutical Sciences, University of São Paulo
- - Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sírio-Libanês. São Paulo
| | - Carolina Hikari Yamada
- - Laboratory of Emerging Infectious Diseases, Pontifical Catholic University of Paraná, Curitiba
- - Hospital Universitário Evangélico Mackenzie, Department of Infectious Diseases, Curitiba
| | - Tatiana A Marins
- - Hospital Israelita Albert Einstein, Department of Clinical Pharmacy, São Paulo
| | | | - Jaques Sztajnbok
- - Instituto de Infectologia Emílio Ribas, São Paulo
- - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (ICr/HC-FMUSP)
| | - Moacyr Silva
- - Hospital Israelita Albert Einstein, Department of Infection Prevention and Control, São Paulo
| | - Bil Randerson Bassetti
- - Hospital Santa Rita de Cássia, Department of Infectious Disease and Infection Control, Vitória ; and
| | - James Albiero
- - Universidade Estadual de Maringá, Pharmacy Department, Programa de Pós-Graduação em Assistência Farmacêutica, Maringá, Brazil
| | - Felipe Francisco Tuon
- - Laboratory of Emerging Infectious Diseases, Pontifical Catholic University of Paraná, Curitiba
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Chiu CY, Sarwal A. Evaluating the Nephrotoxicity of Area-under-the-Curve-Based Dosing of Vancomycin with Concomitant Antipseudomonal Beta-Lactam Antibiotics: A Systematic Review and Meta-Analysis. Medicina (B Aires) 2023; 59:medicina59040691. [PMID: 37109649 PMCID: PMC10146400 DOI: 10.3390/medicina59040691] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
Background and Objectives: Vancomycin combined with piperacillin/tazobactam (vancomycin + piperacillin/tazobactam) has a higher risk of acute kidney injury (AKI) than vancomycin combined with cefepime or meropenem. However, it is uncertain if applying area under the curve (AUC)-based vancomycin dosing has less nephrotoxicity than trough-based dosing in these combinations. Materials and Methods: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception to December 2022. We examined the odds ratio (OR) of AKI between vancomycin + piperacillin/tazobactam and the control group. The control group was defined as vancomycin combined with antipseudomonal beta-lactam antibiotics, except for piperacillin-tazobactam. Results: The OR for AKI is significantly higher in vancomycin + piperacillin/tazobactam compared with the control group (3 studies, 866 patients, OR of 3.861, 95% confidence interval of 2.165 to 6.887, p < 0.05). In the sample population of patients who received vancomycin + piperacillin/tazobactam (2 studies, 536 patients), the risk of AKI (OR of 0.715, 95% CI of 0.439 to 1.163, p = 0.177) and daily vancomycin dose (standard mean difference—0.139, 95% CI—0.458 to 0.179; p = 0.392) are lower by AUC-based dosing than trough-based dosing, although it is not statistically significant. Conclusions: Nephrotoxicity is higher when combined with piperacillin/tazobactam than other antipseudomonal beta-lactam antibiotics (cefepime or meropenem) using the AUC-based dosing. However, applying the AUC-based dosing did not eliminate the risk of AKI or significantly reduce thedaily vancomycin dose compared with the trough-based dosing in the available literature.
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Novy E, Martinière H, Roger C. The Current Status and Future Perspectives of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12040681. [PMID: 37107043 PMCID: PMC10135361 DOI: 10.3390/antibiotics12040681] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Beta-lactams (BL) are the first line agents for the antibiotic management of critically ill patients with sepsis or septic shock. BL are hydrophilic antibiotics particularly subject to unpredictable concentrations in the context of critical illness because of pharmacokinetic (PK) and pharmacodynamics (PD) alterations. Thus, during the last decade, the literature focusing on the interest of BL therapeutic drug monitoring (TDM) in the intensive care unit (ICU) setting has been exponential. Moreover, recent guidelines strongly encourage to optimize BL therapy using a PK/PD approach with TDM. Unfortunately, several barriers exist regarding TDM access and interpretation. Consequently, adherence to routine TDM in ICU remains quite low. Lastly, recent clinical studies failed to demonstrate any improvement in mortality with the use of TDM in ICU patients. This review will first aim at explaining the value and complexity of the TDM process when translating it to critically ill patient bedside management, interpretating the results of clinical studies and discussion of the points which need to be addressed before conducting further TDM studies on clinical outcomes. In a second time, this review will focus on the future aspects of TDM integrating toxicodynamics, model informed precision dosing (MIPD) and “at risk” ICU populations that deserve further investigations to demonstrate positive clinical outcomes.
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Affiliation(s)
- Emmanuel Novy
- Department of Anesthesiology and Critical Care Medicine, Institut Lorrain du Coeur Et Des Vaisseaux, University Hospital of Nancy, Rue du Morvan, 54511 Vandoeuvre-les Nancy, France
- SIMPA, UR 7300, Faculté de Médecine, Maïeutique et Métiers de la Santé, Campus Brabois Santé, University of Lorraine, 54000 Nancy, France
| | - Hugo Martinière
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
| | - Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 30029 Nimes, France
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43
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Arensman Hannan KN, Rivera CG, Fewel N. Vancomycin AUC values estimated with trough-only data: Accuracy in an adult academic medical center population. Am J Health Syst Pharm 2023; 80:452-456. [PMID: 36525590 DOI: 10.1093/ajhp/zxac372] [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: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Vancomycin area under the concentration-time curve (AUC) can be calculated using steady-state serum peak and trough concentrations; however, compared to traditional trough-only monitoring, this approach requires an additional blood sample. Recently published data demonstrated vancomycin AUC estimations using trough-only data with a volume of distribution (Vd) model incorporating age and actual body weight were reasonably accurate and precise in a veteran population. This study sought to extend these methods to a Mayo Clinic adult population. METHODS A retrospective, observational cohort of adult patients with documented steady-state vancomycin peak and trough concentrations was evaluated. Vancomycin AUCs were estimated using trough-only data, and 4 Vd models were assessed for accuracy and precision. Estimated AUCs were compared to AUCs calculated using 1-compartment intermittent infusion equations and steady-state peak and trough ("peak-trough") data. RESULTS The study population (N = 95) was 46% female, with a median age of 59 years and a median weight of 97 kg. Using the VancoPK equation Vd = 0.29 (age in y) + 0.33 (actual weight in kg) + 11, the mean peak-trough and estimated trough-only AUC were 533 and 534, respectively, with a correlation of 0.936. The root mean square error was 47.7, meaning about 95% of AUCs were within 95 mg · h/L of peak-trough AUCs. CONCLUSIONS Accuracy and precision of Vancomycin AUC estimations using trough-only data and the described Vd model were demonstrated in a Mayo Clinic cohort. Targeting an estimated AUC of 500 mg · h/L using the VancoPK model would likely result in an actual AUC within 400 to 600 mg · h/L.
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Affiliation(s)
| | | | - Nathan Fewel
- Department of Pharmacy, Central Texas Veterans Health Care System, Temple, TX, USA
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44
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Development of a Therapeutic Drug Monitoring Strategy for the Optimization of Vincristine Treatment in Pediatric Oncology Populations in Africa. Ther Drug Monit 2023; 45:354-363. [PMID: 36917736 DOI: 10.1097/ftd.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Recent studies have reported ethnic differences in vincristine exposure and outcomes such as toxicity. This resulted in the hypothesis of subtherapeutic dosing in African children. To optimize individual treatment, a strategy to identify subtherapeutic exposure using therapeutic drug monitoring is essential. The aim of the current study was to develop a strategy for therapeutic drug monitoring of vincristine in African children to meet the following criteria: (1) identify patients with low vincristine exposure with sufficient sensitivity (>70%), (2) determine vincristine exposure with a limited sampling strategy design of 3 samples, and (3) allow all samples to be collected within 4 hours after administration. METHODS An in silico simulation study was performed using a previously described population pharmacokinetic model and real-life demographic dataset of Kenyan and Malawian pediatric oncology patients. Two different therapeutic drug monitoring strategies were evaluated: (1) Bayesian approach and (2) pharmacometric nomogram. The sampling design was optimized using the constraints described above. Sensitivity analysis was performed to investigate the influence of missing samples, erroneous sampling times, and different boundaries on the nomogram weight bands. RESULTS With the Bayesian approach, 43.3% of the estimated individual exposure values had a prediction error of ≥20% owing to extremely high shrinkage. The Bayesian approach did not improve with alternative sampling designs within sampling constraints. However, the pharmacometric nomogram could identify patients with low vincristine exposure with a sensitivity, specificity, and accuracy of 75.1%, 76.4%, and 75.9%, respectively. The pharmacometric nomogram performed similarly for different weight bands. CONCLUSIONS The pharmacometric nomogram was able to identify patients with low vincristine exposure with high sensitivity, with 3 blood samples collected at 1, 1.5, and 4 hours after administration. Missing samples should be avoided, and the 3 scheduled samples should be collected within 15, 5, and 15 minutes of 1, 1.5, and 4 hours after administration, respectively.
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Hughes JH, Woo KH, Keizer RJ, Goswami S. Clinical Decision Support for Precision Dosing: Opportunities for Enhanced Equity and Inclusion in Health Care. Clin Pharmacol Ther 2023; 113:565-574. [PMID: 36408716 DOI: 10.1002/cpt.2799] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/13/2022] [Indexed: 11/22/2022]
Abstract
Precision dosing aims to tailor doses to individual patients with the goal of improving treatment efficacy and avoiding toxicity. Clinical decision support software (CDSS) plays a crucial role in mediating this process, translating knowledge derived from clinical trials and real-world data (RWD) into actionable insights for clinicians to use at the point of care. However, not all patient populations are proportionally represented in clinical trials and other data sources that inform CDSS tools, limiting the applicability of these tools for underrepresented populations. Here, we review some of the limitations of existing CDSS tools and discuss methods for overcoming these gaps. We discuss considerations for study design and modeling to create more inclusive CDSS, particularly with an eye toward better incorporation of biological indicators in place of race, ethnicity, or sex. We also review inclusive practices for collection of these demographic data, during both study design and in software user interface design. Because of the role CDSS plays in both recording routine clinical care data and disseminating knowledge derived from data, CDSS presents a promising opportunity to continuously improve precision dosing algorithms using RWD to better reflect the diversity of patient populations.
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Affiliation(s)
| | - Kara H Woo
- InsightRX, San Francisco, California, USA
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46
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Therapeutic Drug Monitoring of Vancomycin Concentrations for the Management of Bone and Joint Infections: An Urgent Need. Trop Med Infect Dis 2023; 8:tropicalmed8020113. [PMID: 36828529 PMCID: PMC9959361 DOI: 10.3390/tropicalmed8020113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023] Open
Abstract
Vancomycin is used for the treatment of bone and joint infections (BJI), but scarce information is available about its pharmacokinetic/pharmacodynamic (PK/PD) characteristics. We aimed to identify the risk factors associated with the non-achievement of an optimal PK/PD target in the first therapeutic drug monitoring (TDM). Methods: A retrospective study was conducted in a tertiary hospital from January 2020 to January 2022. Patients with BJI and TDM of vancomycin on day 2 of treatment were included. Initial vancomycin fixed doses (1 g every 8 h or 12 h) was decided by the responsible doctors. According to TDM results, dosage adjustments were performed. An AUC24h/MIC < 400 mg × h/L, between 400 and 600 mg × h/L and >600 mg × h/L, were defined as suboptimal, optimal and supratherapeutic, respectively. Patients were grouped into these three categories. Demographic, clinical and PK characteristics were compared between groups. Nephrotoxicity at the end of treatment was assessed. Results: A total of 94 patients were included: 22 (23.4%), 42 (44.7%) and 30 (31.9%) presented an infratherapeutic, optimal and supratherapeutic PK/PD targets, respectively. A younger age and initial vancomycin dose <40 mg/kg/day were predictive factors for achieving a suboptimal PK/PD target, while older age, higher serum-creatinine and dose >40 mg/kg/day were associated with overexposure. The nephrotoxicity rate was 22.7%. More than 50% of patients did not achieve an optimal PK/PD. Considering age, baseline serum-creatinine and body weight, TDM is required to readily achieve an optimal and safe exposure.
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47
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Impact of Pharmacist-Led Multidisciplinary Team to Attain Targeted Vancomycin Area under the Curved Monitoring in a Tertiary Care Center in Thailand. Antibiotics (Basel) 2023; 12:antibiotics12020374. [PMID: 36830284 PMCID: PMC9952732 DOI: 10.3390/antibiotics12020374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
Vancomycin Area Under the Curve (AUC) monitoring has been recommended to ensure successful clinical outcomes and minimize the risk of nephrotoxicity, rather than traditional trough concentration. However, vancomycin AUC monitoring by a pharmacist-led multidisciplinary team (PMT) has not been well established in Southeast Asia. This study was conducted at Thammasat University Hospital. Adult patients aged ≥ 18 years who were admitted and received intravenous vancomycin ≥48 h were included. The pre-PMT period (April 2020-September 2020) was defined as a period using traditional trough concentration, while the post-PMT period (October 2020-March 2021) was defined as a period using PMT to monitor vancomycin AUC. The primary outcome was the rate of achievement of the therapeutic target of an AUC/MIC ratio of 400-600. There was a significantly higher rate of achievement of therapeutic target vancomycin AUC during post-PMT period (66.7% vs. 34.3%, p < 0.001). Furthermore, there was a significant improvement in the clinical cure rate (92.4% vs. 69.5%, p < 0.001) and reduction in 30-day ID mortality (2.9% vs. 12.4%, p = 0.017) during the post-PMT period. Our study demonstrates that PMT was effective to help attain a targeted vancomycin AUC, improve the clinical cure rate, and reduce 30-day ID mortality. This intervention should be encouraged to be implemented in Southeast Asia.
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Implementing Vancomycin Population Pharmacokinetic Models: An App for Individualized Antibiotic Therapy in Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12020301. [PMID: 36830212 PMCID: PMC9952184 DOI: 10.3390/antibiotics12020301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/17/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
In individualized therapy, the Bayesian approach integrated with population pharmacokinetic models (PopPK) for predictions together with therapeutic drug monitoring (TDM) to maintain adequate objectives is useful to maximize the efficacy and minimize the probability of toxicity of vancomycin in critically ill patients. Although there are limitations to implementation, model-informed precision dosing (MIPD) is an approach to integrate these elements, which has the potential to optimize the TDM process and maximize the success of antibacterial therapy. The objective of this work was to present an app for individualized therapy and perform a validation of the implemented vancomycin PopPK models. A pragmatic approach was used for selecting the models of Llopis, Goti and Revilla for developing a Shiny app with R. Through ordinary differential equation (ODE)-based mixed effects models from the mlxR package, the app simulates the concentrations' behavior, estimates whether the model was simulated without variability and predicts whether the model was simulated with variability. Moreover, we evaluated the predictive performance with retrospective trough concentration data from patients admitted to the adult critical care unit. Although there were no significant differences in the performance of the estimates, the Llopis model showed better accuracy (mean 80.88%; SD 46.5%); however, it had greater bias (mean -34.47%, SD 63.38%) compared to the Revilla et al. (mean 10.61%, SD 66.37%) and Goti et al. (mean of 13.54%, SD 64.93%) models. With respect to the RMSE (root mean square error), the Llopis (mean of 10.69 mg/L, SD 12.23 mg/L) and Revilla models (mean of 10.65 mg/L, SD 12.81 mg/L) were comparable, and the lowest RMSE was found in the Goti model (mean 9.06 mg/L, SD 9 mg/L). Regarding the predictions, this behavior did not change, and the results varied relatively little. Although our results are satisfactory, the predictive performance in recent studies with vancomycin is heterogeneous, and although these three models have proven to be useful for clinical application, further research and adaptation of PopPK models is required, as well as implementation in the clinical practice of MIPD and TDM in real time.
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Chanapiwat P, Paiboonvong T, Rattanaumpawan P, Montakantikul P. Comparison of the mathematical equation and trapezoidal approach for 24 h area under the plasma concentration-time curve calculation in patients who received intravenous vancomycin in an acute care setting. Pharmacol Res Perspect 2023; 11:e01046. [PMID: 36588162 PMCID: PMC9806189 DOI: 10.1002/prp2.1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/11/2022] [Indexed: 01/03/2023] Open
Abstract
The current recommendation for therapeutic monitoring of vancomycin has recently suggested AUC-guided dosing in patients with serious methicillin-resistant Staphylococcus aureus infections. The study objective was to evaluate mathematical equations and trapezoidal methods for calculating the 24 h area under the plasma vancomycin concentration-time curve (AUC24). The analysis of plasma vancomycin concentrations was performed in 20 adult patients treated with intravenous vancomycin. For each patient, AUC24 was estimated using two methods including, equation and trapezoidal calculation. The AUC24 from two methods was analyzed for correlation. The correlation between the equation and trapezoidal methods was strong. The coefficient of determination (R2 ) values was greater than .99. The two plasma vancomycin concentrations to achieve the highest correlation were concentration at 2.5 to 3 h after starting the infusion and concentration at 1 h before the next dose. Moreover, the AUC24 calculation from trapezoidal and equation methods showed that 19 out of 20 patients (95%) had AUC24 of more than 400 mg·h/L, and more than 50% in this group had AUC24/MIC greater than 600. Of those patients with AUC-trapezoidal >600, 15.38% of patients had trough under 15 mg/L, 15.38% of patients had trough in the range 15 to 20 mg/L and 69.23% of patients had trough more than 20 mg/L. The results of AUC-equation were similar to those of the AUC-trapezoidal method. Our study confirmed that the AUC monitoring is more appropriate than the trough vancomycin concentration. Given these considerations, the AUC-equation method is better and more practical to use in part of a point-of-care treatment, especially in the part of the Bayesian program is not available. The best sampling time point of the peak concentration was 0.5-1 h after 2-h infusion.
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Affiliation(s)
- Pimonrat Chanapiwat
- Department of Pharmacy, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Taniya Paiboonvong
- Department of Pharmacy Practice, College of PharmacyRangsit UniversityPathum ThaniThailand
| | - Pinyo Rattanaumpawan
- Division of Infectious Diseases and Tropical Medicine, Department of Medicine, Faculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Preecha Montakantikul
- Division of Clinical Pharmacy, Department of Pharmacy, Faculty of PharmacyMahidol UniversityBangkokThailand
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The Bayesian-Based Area under the Curve of Vancomycin by Using a Single Trough Level: An Evaluation of Accuracy and Discordance at Tertiary Care Hospital in KSA. Healthcare (Basel) 2023; 11:healthcare11030362. [PMID: 36766937 PMCID: PMC9914540 DOI: 10.3390/healthcare11030362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/01/2023] Open
Abstract
The AUC0-24 is the most accurate way to track the vancomycin level while the Cmin is not an accurate surrogate. Most hospitals in Saudi Arabia are under-practicing the AUC-guided vancomycin dosing and monitoring. No previous work has been conducted to evaluate such practice in the whole kingdom. The current study objective is to calculate the AUC0-24 using the Bayesian dosing software (PrecisePK), identify the probability of patients who receive the optimum dose of vancomycin, and evaluate the accuracy and precision of the Bayesian platform. This retrospective study was conducted at King Abdulaziz medical city, Jeddah. All adult patients treated with vancomycin were included. Pediatric patients, critically ill patients requiring ICU admission, patients with acute renal failure or undergoing dialysis, and febrile neutropenic patients were excluded. The AUC0-24 was predicted using the PrecisePK platform based on the Bayesian principle. The two-compartmental model by Rodvold et al. in this platform and patients' dose data were utilized to calculate the AUC0-24 and trough level. Among 342 patients included in the present study, the mean of the estimated vancomycin AUC0-24 by the posterior model of PrecisePK was 573 ± 199.6 mg, and the model had a bias of 16.8%, whereas the precision was 2.85 mg/L. The target AUC0-24 (400 to 600 mg·h/L) and measured trough (10 to 20 mg/L) were documented in 127 (37.1%) and 185 (54%), respectively. Furthermore, the result demonstrated an increase in odds of AUC0-24 > 600 mg·h/L among trough level 15-20 mg/L group (OR = 13.2, p < 0.05) as compared with trough level 10-14.9 mg/L group. In conclusion, the discordance in the AUC0-24 ratio and measured trough concentration may jeopardize patient safety, and implantation of the Bayesian approach as a workable alternative to the traditional trough method should be considered.
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