1
|
Patel P, Foster CE, Stimes G, Lee SR, Wallace SS. Risk Factors for Treatment Failure in Neonates With Skin and Soft Tissue Infection: A Retrospective Cohort Study. Clin Pediatr (Phila) 2024; 63:689-696. [PMID: 37491834 DOI: 10.1177/00099228231189132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
We aimed to describe the frequency of treatment failure and associated risk factors for treatment failure amongst neonates with skin and soft tissue infections (SSTIs). We conducted a retrospective cohort study of neonates 0 to 28 days old with uncomplicated SSTIs presenting to the emergency department of a quaternary care children's hospital from 2009 to 2017. Data were collected via chart review. Skin and soft tissue infections included the following: cellulitis, abscess, mastitis, perirectal SSTI, carbuncle, and furuncle. Of the 202 neonates in the study, most were term, afebrile with mastitis, or perirectal SSTI. Treatment failure occurred in 8% (17/202) of neonates receiving oral antibiotics; 10 of these neonates had perirectal SSTIs and 2 had clindamycin and methicillin-resistant Staphylococcus aureus. Neonates with treatment failure had increased odds of having perirectal SSTIs (odds ratio [OR] = 4.08, 95% confidence interval [CI] = 1.46-11.31). Further studies are needed to identify strategies to prevent treatment failure in neonates with perirectal SSTIs.
Collapse
Affiliation(s)
- Purva Patel
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Catherine E Foster
- Departments of Infectious Diseases and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Grant Stimes
- Departments of Infectious Diseases and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pharmacy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Su Rin Lee
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pharmacy, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Sowdhamini S Wallace
- Divisions of Pediatric Hospital Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
2
|
Bower WA, Yu Y, Person MK, Parker CM, Kennedy JL, Sue D, Hesse EM, Cook R, Bradley J, Bulitta JB, Karchmer AW, Ward RM, Cato SG, Stephens KC, Hendricks KA. CDC Guidelines for the Prevention and Treatment of Anthrax, 2023. MMWR Recomm Rep 2023; 72:1-47. [PMID: 37963097 PMCID: PMC10651316 DOI: 10.15585/mmwr.rr7206a1] [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] [Indexed: 11/16/2023] Open
Abstract
This report updates previous CDC guidelines and recommendations on preferred prevention and treatment regimens regarding naturally occurring anthrax. Also provided are a wide range of alternative regimens to first-line antimicrobial drugs for use if patients have contraindications or intolerances or after a wide-area aerosol release of Bacillus anthracis spores if resources become limited or a multidrug-resistant B. anthracis strain is used (Hendricks KA, Wright ME, Shadomy SV, et al.; Workgroup on Anthrax Clinical Guidelines. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20:e130687; Meaney-Delman D, Rasmussen SA, Beigi RH, et al. Prophylaxis and treatment of anthrax in pregnant women. Obstet Gynecol 2013;122:885-900; Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics 2014;133:e1411-36). Specifically, this report updates antimicrobial drug and antitoxin use for both postexposure prophylaxis (PEP) and treatment from these previous guidelines best practices and is based on systematic reviews of the literature regarding 1) in vitro antimicrobial drug activity against B. anthracis; 2) in vivo antimicrobial drug efficacy for PEP and treatment; 3) in vivo and human antitoxin efficacy for PEP, treatment, or both; and 4) human survival after antimicrobial drug PEP and treatment of localized anthrax, systemic anthrax, and anthrax meningitis. Changes from previous CDC guidelines and recommendations include an expanded list of alternative antimicrobial drugs to use when first-line antimicrobial drugs are contraindicated or not tolerated or after a bioterrorism event when first-line antimicrobial drugs are depleted or ineffective against a genetically engineered resistant B. anthracis strain. In addition, these updated guidelines include new recommendations regarding special considerations for the diagnosis and treatment of anthrax meningitis, including comorbid, social, and clinical predictors of anthrax meningitis. The previously published CDC guidelines and recommendations described potentially beneficial critical care measures and clinical assessment tools and procedures for persons with anthrax, which have not changed and are not addressed in this update. In addition, no changes were made to the Advisory Committee on Immunization Practices recommendations for use of anthrax vaccine (Bower WA, Schiffer J, Atmar RL, et al. Use of anthrax vaccine in the United States: recommendations of the Advisory Committee on Immunization Practices, 2019. MMWR Recomm Rep 2019;68[No. RR-4]:1-14). The updated guidelines in this report can be used by health care providers to prevent and treat anthrax and guide emergency preparedness officials and planners as they develop and update plans for a wide-area aerosol release of B. anthracis.
Collapse
|
3
|
Developmental Pharmacokinetics of Antibiotics Used in Neonatal ICU: Focus on Preterm Infants. Biomedicines 2023; 11:biomedicines11030940. [PMID: 36979919 PMCID: PMC10046592 DOI: 10.3390/biomedicines11030940] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/22/2023] Open
Abstract
Neonatal Infections are among the most common reasons for admission to the intensive care unit. Neonatal sepsis (NS) significantly contributes to mortality rates. Empiric antibiotic therapy of NS recommended by current international guidelines includes benzylpenicillin, ampicillin/amoxicillin, and aminoglycosides (gentamicin). The rise of antibacterial resistance precipitates the growth of the use of antibiotics of the Watch (second, third, and fourth generations of cephalosporines, carbapenems, macrolides, glycopeptides, rifamycins, fluoroquinolones) and Reserve groups (fifth generation of cephalosporines, oxazolidinones, lipoglycopeptides, fosfomycin), which are associated with a less clinical experience and higher risks of toxic reactions. A proper dosing regimen is essential for effective and safe antibiotic therapy, but its choice in neonates is complicated with high variability in the maturation of organ systems affecting drug absorption, distribution, metabolism, and excretion. Changes in antibiotic pharmacokinetic parameters result in altered efficacy and safety. Population pharmacokinetics can help to prognosis outcomes of antibiotic therapy, but it should be considered that the neonatal population is heterogeneous, and this heterogeneity is mainly determined by gestational and postnatal age. Preterm neonates are common in clinical practice, and due to the different physiology compared to the full terms, constitute a specific neonatal subpopulation. The objective of this review is to summarize the evidence about the developmental changes (specific for preterm and full-term infants, separately) of pharmacokinetic parameters of antibiotics used in neonatal intensive care units.
Collapse
|
4
|
Ways to Improve Insights into Clindamycin Pharmacology and Pharmacokinetics Tailored to Practice. Antibiotics (Basel) 2022; 11:antibiotics11050701. [PMID: 35625345 PMCID: PMC9137603 DOI: 10.3390/antibiotics11050701] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 02/07/2023] Open
Abstract
Given the increase in bacterial resistance and the decrease in the development of new antibiotics, the appropriate use of old antimicrobials has become even more compulsory. Clindamycin is a lincosamide antibiotic approved for adults and children as a drug of choice for systemic treatment of staphylococcal, streptococcal, and gram-positive anaerobic bacterial infections. Because of its profile and high bioavailability, it is commonly used as part of an oral multimodal alternative for prolonged parenteral antibiotic regimens, e.g., to treat bone and joint or prosthesis-related infections. Clindamycin is also frequently used for (surgical) prophylaxis in the event of beta-lactam allergy. Special populations (pediatrics, pregnant women) have altered cytochrome P450 (CYP)3A4 activity. As clindamycin is metabolized by the CYP3A4/5 enzymes to bioactive N-demethyl and sulfoxide metabolites, knowledge of the potential relevance of the drug’s metabolites and disposition in special populations is of interest. Furthermore, drug–drug interactions derived from CYP3A4 inducers and inhibitors, and the data on the impact of the disease state on the CYP system, are still limited. This narrative review provides a detailed survey of the currently available literature on pharmacology and pharmacokinetics and identifies knowledge gaps (special patient population, drug–drug, and drug–disease interactions) to describe a research strategy for precision medicine.
Collapse
|
5
|
Gerhart JG, Carreño FO, Edginton AN, Sinha J, Perrin EM, Kumar KR, Rikhi A, Hornik CP, Harris V, Ganguly S, Cohen-Wolkowiez M, Gonzalez D. Development and Evaluation of a Virtual Population of Children with Obesity for Physiologically Based Pharmacokinetic Modeling. Clin Pharmacokinet 2022; 61:307-320. [PMID: 34617262 PMCID: PMC8813791 DOI: 10.1007/s40262-021-01072-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND AND OBJECTIVE While one in five children in the USA are now obese, and more than three-quarters receive at least one drug during childhood, there is limited dosing guidance for this vulnerable patient population. Physiologically based pharmacokinetic modeling can bridge the gap in the understanding of how pharmacokinetics, including drug distribution and clearance, changes with obesity by incorporating known obesity-related physiological changes in children. The objective of this study was to develop a virtual population of children with obesity to enable physiologically based pharmacokinetic modeling, then use the novel virtual population in conjunction with previously developed models of clindamycin and trimethoprim/sulfamethoxazole to better understand dosing of these drugs in children with obesity. METHODS To enable physiologically based pharmacokinetic modeling, a virtual population of children with obesity was developed using national survey, electronic health record, and clinical trial data, as well as data extracted from the literature. The virtual population accounts for key obesity-related changes in physiology relevant to pharmacokinetics, including increased body size, body composition, organ size and blood flow, plasma protein concentrations, and glomerular filtration rate. The virtual population was then used to predict the pharmacokinetics of clindamycin and trimethoprim/sulfamethoxazole in children with obesity using previously developed physiologically based pharmacokinetic models. RESULTS Model simulations predicted observed concentrations well, with an overall average fold error of 1.09, 1.24, and 1.53 for clindamycin, trimethoprim, and sulfamethoxazole, respectively. Relative to children without obesity, children with obesity experienced decreased clindamycin and trimethoprim/sulfamethoxazole weight-normalized clearance and volume of distribution, and higher absolute doses under recommended pediatric weight-based dosing regimens. CONCLUSIONS Model simulations support current recommended weight-based dosing in children with obesity for clindamycin and trimethoprim/sulfamethoxazole, as they met target exposure despite these changes in clearance and volume of distribution.
Collapse
Affiliation(s)
- Jacqueline G Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Fernando O Carreño
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | | | - Jaydeep Sinha
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Eliana M Perrin
- Department of Pediatrics, School of Medicine and School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Karan R Kumar
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Aruna Rikhi
- Duke Clinical Research Institute, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Vincent Harris
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
| | - Samit Ganguly
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Campus Box #7569, Chapel Hill, NC, 27599-7569, USA.
| |
Collapse
|
6
|
Jackson W, Gonzalez D, Smith PB, Ambalavanan N, Atz AM, Sokol GM, Hornik CD, Stewart D, Mundakel G, Poindexter BB, Ahlfeld SK, Mills M, Cohen-Wolkowiez M, Martz K, Hornik CP, Laughon MM. Safety of sildenafil in extremely premature infants: a phase I trial. J Perinatol 2022; 42:31-36. [PMID: 34741102 PMCID: PMC8569839 DOI: 10.1038/s41372-021-01261-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To characterize the safety of sildenafil in premature infants. STUDY DESIGN A phase I, open-label trial of sildenafil in premature infants receiving sildenafil per usual clinical care (cohort 1) or receiving a single IV dose of sildenafil (cohort 2). Safety was evaluated based on adverse events (AEs), transaminase levels, and mean arterial pressure monitoring. RESULTS Twenty-four infants in cohort 1 (n = 25) received enteral sildenafil. In cohort 2, infants received a single IV sildenafil dose of 0.25 mg/kg (n = 7) or 0.125 mg/kg (n = 2). In cohort 2, there was one serious AE related to study drug involving hypotension associated with a faster infusion rate than specified by the protocol. There were no AEs related to elevated transaminases. CONCLUSION Sildenafil was well tolerated by the study population. Drug administration times and flush rates require careful attention to prevent infusion-related hypotension associated with faster infusions of IV sildenafil in premature infants. CLINICAL TRIAL ClinicalTrials.gov Identifier: NCT01670136.
Collapse
Affiliation(s)
- Wesley Jackson
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Gregory M Sokol
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Dan Stewart
- University of Louisville Norton Children's Hospital, Louisville, KY, USA
| | - Gratias Mundakel
- Kings County Hospital Center/SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Brenda B Poindexter
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Shawn K Ahlfeld
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mary Mills
- Duke Clinical Research Institute, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Matthew M Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
7
|
Tu Q, Cotta M, Raman S, Graham N, Schlapbach L, Roberts JA. Individualized precision dosing approaches to optimize antimicrobial therapy in pediatric populations. Expert Rev Clin Pharmacol 2021; 14:1383-1399. [PMID: 34313180 DOI: 10.1080/17512433.2021.1961578] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction:Severe infections continue to impose a major burden on critically ill children and mortality rates remain stagnant. Outcomes rely on accurate and timely delivery of antimicrobials achieving target concentrations in infected tissue. Yet, developmental aspects, disease-related variables, and host factors may severely alter antimicrobial pharmacokinetics in pediatrics. The emergence of antimicrobial resistance increases the need for improved treatment approaches.Areas covered:This narrative review explores why optimization of antimicrobial therapy in neonates, infants, children, and adolescents is crucial and summarizes the possible dosing approaches to achieve antimicrobial individualization. Finally, we outline a roadmap toward scientific evidence informing the development and implementation of precision antimicrobial dosing in critically ill children.The literature search was conducted on PubMed using the following keywords: neonate, infant, child, adolescent, pediatrics, antimicrobial, pharmacokinetic, pharmacodynamic target, Bayes dosing software, optimizing, individualizing, personalizing, precision dosing, drug monitoring, validation, attainment, and software implementation. Further articles were sought from the references of the above searched articles.Expert opinion:Recently, technological innovations have emerged that enabled the development of individualized antimicrobial dosing approaches in adults. More work is required in pediatrics to make individualized antimicrobial dosing approaches widely operationalized in this population.
Collapse
Affiliation(s)
- Quyen Tu
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Menino Cotta
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Sainath Raman
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Centre for Children's Health Research (CCHR), The University of Queensland, Brisbane, QLD, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Luregn Schlapbach
- Department of Paediatric Intensive Care Medicine, Queensland Children's Hospital, Brisbane, QLD, Australia.,Department of Intensive Care and Neonatology, The University Children's Hospital Zurich, Switzerland
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| |
Collapse
|
8
|
Miller LE, DeRienzo C, Smith PB, Bose C, Clark RH, Cotten CM, Benjamin DK, Hornik CD, Greenberg RG. Association between neonatal intensive care unit medication safety practices, adverse events, and death. J Perinatol 2021; 41:1739-1744. [PMID: 33033390 DOI: 10.1038/s41372-020-00857-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 09/15/2020] [Accepted: 09/26/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Determine the associations between neonatal intensive care unit (NICU) medication safety practices, laboratory-based adverse events (lab-AEs), and death. STUDY DESIGN We combined data from a 2016 survey of Pediatrix NICUs on use of medication safety practices with 2014-2016 infant data. We grouped NICUs based on the number of safety practices used (≤5, 6-7, and 8-10) and evaluated the association between the number of safety practices used and lab-AEs and deaths using logistic regressions. RESULTS Of the 94 NICUs included, 17% used ≤5 medication safety practices, 51% used 6-7, and 32% used 8-10. NICUs with more safety practices did not have a difference in lab-AEs or death. CONCLUSION In this cohort, the use of more medication safety practices was not associated with fewer lab-AEs or decreased death.
Collapse
Affiliation(s)
- Laura E Miller
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Chris DeRienzo
- Department of Medicine, Division of Population Health, Stanford University, Stanford, CA, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Carl Bose
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | | | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
| |
Collapse
|
9
|
Smith MJ, Boutzoukas A, Autmizguine J, Hudak ML, Zinkhan E, Bloom BT, Heresi G, Lavery AP, Courtney SE, Sokol GM, Cotten CM, Bliss JM, Mendley S, Bendel C, Dammann CE, Weitkamp JH, Saxonhouse MA, Mundakel GT, Debski J, Sharma G, Erinjeri J, Gao J, Benjamin DK, Hornik CP, Smith PB, Cohen-Wolkowiez M. Antibiotic Safety and Effectiveness in Premature Infants With Complicated Intraabdominal Infections. Pediatr Infect Dis J 2021; 40:550-555. [PMID: 33902072 PMCID: PMC9844130 DOI: 10.1097/inf.0000000000003034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In premature infants, complicated intraabdominal infections (cIAIs) are a leading cause of morbidity and mortality. Although universally prescribed, the safety and effectiveness of commonly used antibiotic regimens have not been established in this population. METHODS Infants ≤33 weeks gestational age and <121 days postnatal age with cIAI were randomized to ≤10 days of ampicillin, gentamicin, and metronidazole (group 1); ampicillin, gentamicin, and clindamycin (group 2); or piperacillin-tazobactam and gentamicin (group 3) at doses stratified by postmenstrual age. Due to slow enrollment, a protocol amendment allowed eligible infants already receiving study regimens to enroll without randomization. The primary outcome was mortality within 30 days of study drug completion. Secondary outcomes included adverse events, outcomes of special interest, and therapeutic success (absence of death, negative cultures, and clinical cure score >4) 30 days after study drug completion. RESULTS One hundred eighty infants [128 randomized (R), 52 nonrandomized (NR)] were enrolled: 63 in group 1 (45 R, 18 NR), 47 in group 2 (41 R, 6 NR), and 70 in group 3 (42 R, 28 NR). Thirty-day mortality was 8%, 7%, and 9% in groups 1, 2, and 3, respectively. There were no differences in safety outcomes between antibiotic regimens. After adjusting for treatment group and gestational age, mortality rates through end of follow-up were 4.22 [95% confidence interval (CI): 1.39-12.13], 4.53 (95% CI: 1.21-15.50), and 4.07 (95% CI: 1.22-12.70) for groups 1, 2, and 3, respectively. CONCLUSIONS Each of the antibiotic regimens are safe in premature infants with cIAI. CLINICAL TRIAL REGISTRATION NCT0199499.
Collapse
Affiliation(s)
- Michael J. Smith
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
| | | | - Julie Autmizguine
- Division of Pediatric Infectious Diseases, Universitaire Sainte-Justine, Montreal, Canada
| | - Mark L. Hudak
- Division of Neonatology, University of Florida College of Medicine, Jacksonville, FL
| | - Erin Zinkhan
- Division of Neonatology, University of Utah, Salt Lake City, UT
| | - Barry T. Bloom
- Division of Neonatology, Wesley Medical Center, Wichita, KS
| | - Gloria Heresi
- Division of Pediatric Infectious Diseases, University of Texas, Houston, TX
| | | | - Sherry E. Courtney
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - C. Michael Cotten
- Division of Neonatal-Perinatal Medicine, Duke University, Durham, NC
| | | | - Susan Mendley
- Division of Nephrology, University of Maryland, Baltimore, MD
| | - Catherine Bendel
- Division of Neonatology, University of Minnesota, Minneapolis, MN
| | | | | | | | | | | | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, NC
| | - Daniel K. Benjamin
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | - P. Brian Smith
- Division of Neonatal-Perinatal Medicine, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Michael Cohen-Wolkowiez
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
10
|
Abduljalil K, Pan X, Pansari A, Jamei M, Johnson TN. A Preterm Physiologically Based Pharmacokinetic Model. Part I: Physiological Parameters and Model Building. Clin Pharmacokinet 2021; 59:485-500. [PMID: 31583613 DOI: 10.1007/s40262-019-00825-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Developmental physiology can alter pharmacotherapy in preterm populations. Because of ethical and clinical constraints in studying this vulnerable age group, physiologically based pharmacokinetic models offer a viable alternative approach to predicting drug pharmacokinetics and pharmacodynamics in this population. However, such models require comprehensive information on the changes of anatomical, physiological and biochemical variables, where such data are not available in a single source. OBJECTIVE The objective of this study was to integrate the relevant physiological parameters required to build a physiologically based pharmacokinetic model for the preterm population. METHODS Published information on developmental preterm physiology and some drug-metabolising enzymes were collated and analysed. Equations were generated to describe the changes in parameter values during growth. RESULTS Data on organ size show different growth patterns that were quantified as functions of bodyweight to retain physiological variability and correlation. Protein binding data were quantified as functions of age as the body weight was not reported in the original articles. Ontogeny functions were derived for cytochrome P450 1A2, 3A4 and 2C9. Tissue composition values and how they change with age are limited. CONCLUSIONS Despite the limitations identified in the availability of some tissue composition values, the data presented in this article provide an integrated resource of system parameters needed for building a preterm physiologically based pharmacokinetic model.
Collapse
Affiliation(s)
- Khaled Abduljalil
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK.
| | - Xian Pan
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Amita Pansari
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Masoud Jamei
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Trevor N Johnson
- Simcyp Division Level 2-Acero, Certara UK Limited, 1 Concourse Way, Sheffield, S1 2BJ, UK
| |
Collapse
|
11
|
Preterm Physiologically Based Pharmacokinetic Model. Part II: Applications of the Model to Predict Drug Pharmacokinetics in the Preterm Population. Clin Pharmacokinet 2021; 59:501-518. [PMID: 31587145 DOI: 10.1007/s40262-019-00827-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Preterm neonates are usually not part of a traditional drug development programme, however they are frequently administered medicines. Developing modelling and simulation tools, such as physiologically based pharmacokinetic (PBPK) models that incorporate developmental physiology and maturation of drug metabolism, can be used to predict drug exposure in this group of patients, and may help to optimize drug dose adjustment. OBJECTIVE The aim of this study was to assess and verify the predictability of a preterm PBPK model using compounds that undergo diverse renal and/or hepatic clearance based on the knowledge of their disposition in adults. METHODS A PBPK model was developed in the Simcyp Simulator V17 to predict the pharmacokinetics (PK) of drugs in preterm neonates. Drug parameters for alfentanil, midazolam, caffeine, ibuprofen, gentamicin and vancomycin were collated from the literature. Predicted PK parameters and profiles were compared against the observed data. RESULTS The preterm PBPK model predicted the PK changes of the six compounds using ontogeny functions for cytochrome P450 (CYP) 1A2, CYP2C9 and CYP3A4 after oral and intravenous administrations. For gentamicin and vancomycin, the maturation of renal function was able to predict the exposure of these two compounds after intravenous administration. All PK parameter predictions were within a twofold error criteria. CONCLUSION While the developed preterm model for the prediction of PK behaviour in preterm patients is not intended to replace clinical studies, it can potentially help with deciding on first-time dosing in this population and study design in the absence of clinical data.
Collapse
|
12
|
Chang HP, Kim SJ, Wu D, Shah K, Shah DK. Age-Related Changes in Pediatric Physiology: Quantitative Analysis of Organ Weights and Blood Flows. AAPS JOURNAL 2021; 23:50. [DOI: 10.1208/s12248-021-00581-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 03/11/2021] [Indexed: 02/08/2023]
|
13
|
Mfoafo KA, Omidian M, Bertol CD, Omidi Y, Omidian H. Neonatal and pediatric oral drug delivery: Hopes and hurdles. Int J Pharm 2021; 597:120296. [PMID: 33524524 DOI: 10.1016/j.ijpharm.2021.120296] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
The neonatal and pediatric populations have long been neglected concerning the development of oral dosage forms. For close to two decades, caregivers have had to adjust the doses of the off-label medicines and drugs for adults to suit the neonatal and pediatric needs. This is due to the lack of rules and regulations regarding neonates and pediatrics clinical trials while pharmaceutical industries see this as a non-lucrative approach. Despite such limitations, the administration of solid and liquid dosage forms to neonates and pediatrics necessitates the development of new technologies and even new strategies to meet the needs. Current approaches have not only focused on the development of suitable dosage forms but also the advancement of devices to enhance drug administration to pediatrics and neonates. Though current approaches have significantly added to the number of pediatric and neonatal oral dosage formulations on the market, there is still more room for improvement(s). While novel dosage forms including multiparticulates, orodispersible tablets/films, and chewable tablets have extensively been researched, some administration devices (e.g., nipple shield, pill swallowing cup, and solid dosage pen) have also been explored. Although a few of these products are in the market, the concerted efforts of regulation administrative bodies, pharmaceutical industry settings, and scientists in academia have been oriented to address all issues and advance the neonatal and pediatric-centric pharmaceutical products.
Collapse
Affiliation(s)
| | | | | | - Yadollah Omidi
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Hossein Omidian
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, USA.
| |
Collapse
|
14
|
Aleem S, Wohlfarth M, Cotten CM, Greenberg RG. Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit. Semin Perinatol 2020; 44:151326. [PMID: 33158599 PMCID: PMC7550069 DOI: 10.1016/j.semperi.2020.151326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Suspected or proven late onset sepsis, necrotizing enterocolitis, urinary tract infections, and ventilator associated pneumonia occurring after the first postnatal days contribute significantly to the total antibiotic exposures in neonatal intensive care units. The variability in definitions and diagnostic criteria in these conditions lead to unnecessary antibiotic use. The length of treatment and choice of antimicrobial agents for presumed and proven episodes also vary among centers due to a lack of supportive evidence and guidelines. Implementation of robust antibiotic stewardship programs can encourage compliance with appropriate dosages and narrow-spectrum regimens.
Collapse
Affiliation(s)
- Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | | | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA,Corresponding author at: Department of Pediatrics, Duke University, Durham, NC, USA
| |
Collapse
|
15
|
Maharaj AR, Wu H, Hornik CP, Arrieta A, James L, Bhatt-Mehta V, Bradley J, Muller WJ, Al-Uzri A, Downes KJ, Cohen-Wolkowiez M. Use of normalized prediction distribution errors for assessing population physiologically-based pharmacokinetic model adequacy. J Pharmacokinet Pharmacodyn 2020; 47:199-218. [PMID: 32323049 PMCID: PMC7293575 DOI: 10.1007/s10928-020-09684-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 03/27/2020] [Indexed: 12/19/2022]
Abstract
Currently employed methods for qualifying population physiologically-based pharmacokinetic (Pop-PBPK) model predictions of continuous outcomes (e.g., concentration-time data) fail to account for within-subject correlations and the presence of residual error. In this study, we propose a new method for evaluating Pop-PBPK model predictions that account for such features. The approach focuses on deriving Pop-PBPK-specific normalized prediction distribution errors (NPDE), a metric that is commonly used for population pharmacokinetic model validation. We describe specific methodological steps for computing NPDE for Pop-PBPK models and define three measures for evaluating model performance: mean of NPDE, goodness-of-fit plots, and the magnitude of residual error. Utility of the proposed evaluation approach was demonstrated using two simulation-based study designs (positive and negative control studies) as well as pharmacokinetic data from a real-world clinical trial. For the positive-control simulation study, where observations and model simulations were generated under the same Pop-PBPK model, the NPDE-based approach denoted a congruency between model predictions and observed data (mean of NPDE = - 0.01). In contrast, for the negative-control simulation study, where model simulations and observed data were generated under different Pop-PBPK models, the NPDE-based method asserted that model simulations and observed data were incongruent (mean of NPDE = - 0.29). When employed to evaluate a previously developed clindamycin PBPK model against prospectively collected plasma concentration data from 29 children, the NPDE-based method qualified the model predictions as successful (mean of NPDE = 0). However, when pediatric subpopulations (e.g., infants) were evaluated, the approach revealed potential biases that should be explored.
Collapse
Affiliation(s)
- Anil R Maharaj
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Antonio Arrieta
- Children's Hospital of Orange County Research Institute, Orange, CA, USA
| | - Laura James
- Arkansas Children's Hospital Research Center, Little Rock, AR, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Varsha Bhatt-Mehta
- University of Michigan College of Pharmacy and Michigan Medicine, Ann Arbor, MI, USA
| | - John Bradley
- Rady Children's Hospital and Health Center, San Diego, CA, USA
| | - William J Muller
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, USA
| | - Kevin J Downes
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
| |
Collapse
|
16
|
Ye PP, Zheng Y, Du B, Liu XT, Tang BH, Kan M, Zhou Y, Hao GX, Huang X, Su LQ, Wang WQ, Yu F, Zhao W. First dose in neonates: pharmacokinetic bridging study from juvenile mice to neonates for drugs metabolized by CYP3A. Xenobiotica 2020; 50:1275-1284. [PMID: 32400275 DOI: 10.1080/00498254.2020.1768454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
First dose prediction is challenging in neonates. Our objective in this proof-of-concept study was to perform a pharmacokinetic (PK) bridging study from juvenile mice to neonates for drugs metabolized by CYP3A. We selected midazolam and clindamycin as model drugs. We developed juvenile mice population PK models using NONMEM. The PK parameters of these two drugs in juvenile mice were used to bridge PK parameters in neonates using different correction methods. The bridging results were evaluated by the fold-error of 0.5- to 1.5-fold. Simple allometry with and without a correction factor for maximum lifespan potential could be used for a bridging of clearance (CL) and volume of distribution (Vd), respectively, from juvenile mice to neonates. Simulation results demonstrated that for midazolam, 100% of clinical studies for which both the predictive CL and Vd were within 0.5- to 1.5-fold of the observed. For clindamycin, 75% and 100% of clinical studies for which the predictive CL and Vd were within 0.5- to 1.5-fold of the observed. A PK bridging of drugs metabolized by CYP3A is feasible from juvenile mice to neonates. It could be a complement to the ADE and PBPK models to support the first dose in neonates.
Collapse
Affiliation(s)
- Pan-Pan Ye
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Yi Zheng
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bin Du
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xi-Ting Liu
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Min Kan
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yue Zhou
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xin Huang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Le-Qun Su
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Wen-Qi Wang
- Clinical Research Center, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Feng Yu
- Department of Clinical Pharmacy, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Wei Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Clinical Research Center, The First Affiliated Hospital of Shandong First Medical University, Jinan, China.,Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| |
Collapse
|
17
|
Abstract
BACKGROUND Despite the absence of adequate safety or efficacy data, clindamycin is widely prescribed in the neonatal intensive care unit. We evaluated the association between clindamycin exposure and adverse events, as well as antibiotic effectiveness in infants. METHODS This was a retrospective cohort study of infants receiving clindamycin before postnatal day 121 who were discharged from a Pediatrix Medical Group neonatal intensive care unit (1997-2015). Using a previously developed pharmacokinetic model, we performed simulations to predict clindamycin exposure based on available dosing data. We used multivariable logistic regression to evaluate the association between clindamycin exposure and safety outcomes during and after clindamycin therapy. We reported the proportion of infants with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and clearance of MRSA bacteremia. RESULTS A total of 4089 infants received clindamycin at a median (25th-75th percentile) dose of 15 mg/kg/d (12-16). Clearance increased with older gestational age. Infants with the highest total clindamycin exposure had marginally increased odds of necrotizing enterocolitis within 7 days (adjusted odds ratio = 1.95 [1.04-3.63]), but exposure was not associated with death, sepsis, seizures, intestinal perforation or intestinal strictures. Of 25 infants who had MRSA bacteremia, 19 (76%) cleared the infection by the end of the clindamycin course. CONCLUSIONS Higher clindamycin exposure was not associated with increased odds of death or nonlaboratory adverse events. The use of pharmacokinetic models combined with available electronic health record data offers a valuable, cost-effective approach to analyzing the safety and effectiveness of drugs in infants when large-scale trials are not feasible.
Collapse
|
18
|
Borella E, Oosterholt S, Magni P, Della Pasqua O. Use of prior knowledge and extrapolation in paediatric drug development: A case study with deferasirox. Eur J Pharm Sci 2019; 136:104931. [PMID: 31108206 DOI: 10.1016/j.ejps.2019.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 03/09/2019] [Accepted: 05/13/2019] [Indexed: 01/19/2023]
Abstract
The characterisation of pharmacokinetics, pharmacodynamics and dose-exposure-response relationships requires data arising from well-designed study protocols and a relatively large sample from the target patient population. Such a prerequisite is unrealistic for paediatric rare diseases, where the patient population is often vulnerable and very small. In such cases, different sources of data and knowledge need to be considered to ensure trial designs are truly informative and oncoming data can be analysed efficiently. Here, we use clinical trial simulations to assess the contribution of historical data for (1) the analysis of sparse samples from a limited number of children and (2) the optimisation of study design when an increase in the number of subjects is not feasible. The evaluation of the pharmacokinetics of deferasirox in paediatric patients affected by haemoglobinopathies was used as case study. Our investigation shows that the incorporation of prior knowledge increases parameter precision and probability of successful convergence from only 12% with no priors to 56% and 75% for weakly and highly informative priors, respectively. In addition, results suggest that even when only one sample is collected per subject, as implemented in the original trial and in many other examples in clinical research, there is a 60% probability of biased parameter estimates (>25%). In conjunction with adult prior information and optimisation techniques, the probability of bias could be limited to <20% by increasing the number of samples/subject from 1 to 3. The methodology described here can be easily applied to other studies in small populations.
Collapse
Affiliation(s)
- Elisa Borella
- Dipart. Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - Sean Oosterholt
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK
| | - Paolo Magni
- Dipart. Ingegneria Industriale e dell'Informazione, Università degli Studi di Pavia, Pavia, Italy
| | - Oscar Della Pasqua
- Clinical Pharmacology & Therapeutics Group, University College London, London, UK; Clinical Pharmacology Modelling & Simulation, GlaxoSmithKline, Uxbridge, UK.
| |
Collapse
|
19
|
Abstract
Optimization of antimicrobial treatment is a cornerstone in the fight against antimicrobial resistance. Various national and international authorities and professional veterinary and farming associations have released generic guidelines on prudent antimicrobial use in animals. However, these generic guidelines need to be translated into a set of animal species- and disease-specific practice recommendations. This article focuses on prevention of antimicrobial resistance and its complex relationship with treatment efficacy, highlighting key situations where the current antimicrobial drug products, treatment recommendations, and practices may be insufficient to minimize antimicrobial selection. The authors address this topic using a multidisciplinary approach involving microbiology, pharmacology, clinical medicine, and animal husbandry. In the first part of the article, we define four key targets for implementing the concept of optimal antimicrobial treatment in veterinary practice: (i) reduction of overall antimicrobial consumption, (ii) improved use of diagnostic testing, (iii) prudent use of second-line, critically important antimicrobials, and (iv) optimization of dosage regimens. In the second part, we provided practice recommendations for achieving these four targets, with reference to specific conditions that account for most antimicrobial use in pigs (intestinal and respiratory disease), cattle (respiratory disease and mastitis), dogs and cats (skin, intestinal, genitourinary, and respiratory disease), and horses (upper respiratory disease, neonatal foal care, and surgical infections). Lastly, we present perspectives on the education and research needs for improving antimicrobial use in the future.
Collapse
|
20
|
Neely M, Bayard D, Desai A, Kovanda L, Edginton A. Pharmacometric Modeling and Simulation Is Essential to Pediatric Clinical Pharmacology. J Clin Pharmacol 2018; 58 Suppl 10:S73-S85. [DOI: 10.1002/jcph.1316] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/17/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Michael Neely
- Children's Hospital Los Angeles; University of Southern California; Los Angeles CA USA
| | - David Bayard
- Children's Hospital Los Angeles; University of Southern California; Los Angeles CA USA
| | - Amit Desai
- Astellas Pharma Global Development, Inc.; Northbrook IL USA
| | - Laura Kovanda
- Astellas Pharma Global Development, Inc.; Northbrook IL USA
| | | |
Collapse
|
21
|
Maharaj AR, Gonzalez D, Cohen-Wolkowiez M, Hornik CP, Edginton AN. Improving Pediatric Protein Binding Estimates: An Evaluation of α1-Acid Glycoprotein Maturation in Healthy and Infected Subjects. Clin Pharmacokinet 2018; 57:577-589. [PMID: 28779462 PMCID: PMC5797516 DOI: 10.1007/s40262-017-0576-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Differences in plasma protein levels observed between children and adults can alter the extent of xenobiotic binding in plasma, resulting in divergent patterns of exposure. OBJECTIVE This study aims to quantify the ontogeny of α1-acid glycoprotein in both healthy and infected subjects. METHODS Data pertaining to α1-acid glycoprotein from healthy subjects were compiled over 26 different publications. For subjects diagnosed or suspected of infection, α1-acid glycoprotein levels were obtained from 214 individuals acquired over three clinical investigations. The analysis evaluated the use of linear, power, exponential, log-linear, and sigmoid E max models to describe the ontogeny of α1-acid glycoprotein. Utility of the derived ontogeny equation for estimation of pediatric fraction unbound was evaluated using average-fold error and absolute average-fold error as measures of bias and precision, respectively. A comparison to fraction unbound estimates derived using a previously proposed linear equation was also instituted. RESULTS The sigmoid E max model provided the comparatively best depiction of α1-acid glycoprotein ontogeny in both healthy and infected subjects. Despite median α1-acid glycoprotein levels in infected subjects being more than two-fold greater than those observed in healthy subjects, a similar ontogeny pattern was observed when levels were normalized toward adult levels. For estimation of pediatric fraction unbound, the α1-acid glycoprotein ontogeny equation derived from this work (average fold error 0.99; absolute average fold error 1.24) provided a superior predictive performance in comparison to the previous equation (average fold error 0.74; absolute average fold error 1.45). CONCLUSION The current investigation depicts a proficient modality for estimation of protein binding in pediatrics and will, therefore, aid in reducing uncertainty associated with pediatric pharmacokinetic predictions.
Collapse
Affiliation(s)
- Anil R Maharaj
- School of Pharmacy, University of Waterloo, 10A Victoria St. S, Kitchener, ON, Canada
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Andrea N Edginton
- School of Pharmacy, University of Waterloo, 10A Victoria St. S, Kitchener, ON, Canada.
| |
Collapse
|
22
|
Rivera-Chaparro ND, Cohen-Wolkowiez M, Greenberg RG. Dosing antibiotics in neonates: review of the pharmacokinetic data. Future Microbiol 2017; 12:1001-1016. [PMID: 28758800 PMCID: PMC5627030 DOI: 10.2217/fmb-2017-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/23/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are often used in neonates despite the absence of relevant dosing information in drug labels. For neonatal dosing, clinicians must extrapolate data from studies for adults and older children, who have strikingly different physiologies. As a result, dosing extrapolation can lead to increased toxicity or efficacy failures in neonates. Driven by these differences and recent legislation mandating the study of drugs in children and neonates, an increasing number of pharmacokinetic studies of antibiotics are being performed in neonates. These studies have led to new dosing recommendations with particular consideration for neonate body size and maturation. Herein, we highlight the available pharmacokinetic data for commonly used systemic antibiotics in neonates.
Collapse
Affiliation(s)
- Nazario D Rivera-Chaparro
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| |
Collapse
|
23
|
Smith MJ, Gonzalez D, Goldman JL, Yogev R, Sullivan JE, Reed MD, Anand R, Martz K, Berezny K, Benjamin DK, Smith PB, Cohen-Wolkowiez M, Watt K. Pharmacokinetics of Clindamycin in Obese and Nonobese Children. Antimicrob Agents Chemother 2017; 61:e02014-16. [PMID: 28137820 PMCID: PMC5365720 DOI: 10.1128/aac.02014-16] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 01/12/2017] [Indexed: 12/12/2022] Open
Abstract
Although obesity is prevalent among children in the United States, pharmacokinetic (PK) data for obese children are limited. Clindamycin is a commonly used antibiotic that may require dose adjustment in obese children due to its lipophilic properties. We performed a clindamycin population PK analysis using data from three separate trials. A total of 420 samples from 220 children, 76 of whom had a body mass index greater than or equal to the 95th percentile for age, were included in the analysis. Compared to other metrics, total body weight (TBW) was the most robust measure of body size. The final model included TBW and a sigmoidal maturation relationship between postmenstrual age (PMA) and clearance (CL): CL (liters/hour) = 13.8 × (TBW/70)0.75 × [PMA2.83/(39.52.83+PMA2.83)]; volume of distribution (V) was associated with TBW, albumin (ALB), and alpha-1 acid glycoprotein (AAG): V (liters) = 63.6 × (TBW/70) × (ALB/3.3)-0.83 × (AAG/2.4)-0.25 After accounting for differences in TBW, obesity status did not explain additional interindividual variability in model parameters. Our findings support TBW-based dosing for obese and nonobese children.
Collapse
Affiliation(s)
- Michael J Smith
- Division of Pediatric Infectious Diseases, University of Louisville, Louisville, Kentucky, USA
- Kosair Charities Pediatric Clinical Research Unit, University of Louisville, Louisville, Kentucky, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Ram Yogev
- Northwestern University, Chicago, Illinois, USA
| | - Janice E Sullivan
- Kosair Charities Pediatric Clinical Research Unit, University of Louisville, Louisville, Kentucky, USA
| | | | | | | | - Katherine Berezny
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - P Brian Smith
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | | |
Collapse
|
24
|
Antimicrobial Agent Dosing in Infants. Clin Ther 2016; 38:1948-60. [DOI: 10.1016/j.clinthera.2016.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 11/19/2022]
|