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Wang H, Li D, Jiang Y, Liang J, Yu Q, Kuang L, Huang Y, Qin D, Li P, He J, Xu F, Li X, Wang F, Wei Y, Li X. Population pharmacokinetics of fluconazole for prevention or treatment of invasive candidiasis in Chinese young infants. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03184-7. [PMID: 38850301 DOI: 10.1007/s00210-024-03184-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/24/2024] [Indexed: 06/10/2024]
Abstract
The dosing of fluconazole for young infants remains empirical because of the limited pharmacokinetic (PK) data. We aimed to establish a population PK model and assess the systematic exposure-response of commonly used regimens of fluconazole in Chinese infants. We included infants with a postnatal age of less than 120 days and received intravenous fluconazole. Both scheduled and scavenged plasma samples were collected, and fluconzaole concentration was determined by a validated ultra-performance liquid chromatography-tandem mass spectrometry assay. Population PK analysis was conducted using Phoenix NLME, and then Monte Carlo simulation was conducted to predict the probability of target attainment (PTA) of empirically used regimens of both prophylactic and therapeutic purposes. Based on 304 plasma samples from 183 young infants, fluconazole concentration data was best described by a one-compartment model with first-order elimination. Gestational Age (GA), postnatal age (PNA), and body weight (BW) were included in the final model as CL = 0.02*(GA/214)2.77*(PNA/13)0.24*exp(nCL); V = 1.56*(BW/1435)0.90*exp(nV). Model validation revealed the final model had qualified stability and acceptable predictive properties. Monte Carlo simulation indicated that under the same minimum inhibitory concentration (MIC) value and administration regimen, PTA decreased with GA and PNA. The commonly used prophylactic regimens can meet the clinical need, while higher doses might be needed for treatment of invasive candidiasis. This population PK model of fluconazole discriminated the impact of GA and PNA on CL and BW on V. Dosing adjustment was needed according to the GA and PNA of infants to achieve targeted exposures.
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Affiliation(s)
- Honghong Wang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China
| | - Yongjiang Jiang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Jing Liang
- Department of Neonatology, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Qiaoai Yu
- Department of Laboratory, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Linghong Kuang
- School of Computer Science and Mathematics, Fujian University of Technology, Fuzhou, Fujian, China
| | - Yuling Huang
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Dongjie Qin
- Pharmaceutical Division, Liuzhou Quality Inspection and Testing Research Center, Liuzhou, Guangxi, China
| | - Ping Li
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Jing He
- Department of Pharmacy, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Feng Xu
- Department of Pharmacy, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Xueli Li
- Department of Laboratory, Liuzhou Hospital of Guangzhou Women and Children's Medical Center, Liuzhou, Guangxi, China
| | - Fei Wang
- Department of Pharmacy, Fujian Provincial Geriatric Hospital, Teaching Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanfei Wei
- Department of Neonatology, Liuzhou Maternity and Child Healthcare Hospital, Affiliated Maternity Hospital and Affiliated Children's Hospital of Guangxi University of Science and Technology, Liuzhou, Guangxi, China.
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University,, Beijing, China.
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2
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Randell RL, Balevic SJ, Greenberg RG, Cohen-Wolkowiez M, Thompson EJ, Venkatachalam S, Smith MJ, Bendel C, Bliss JM, Chaaban H, Chhabra R, Dammann CEL, Downey LC, Hornik C, Hussain N, Laughon MM, Lavery A, Moya F, Saxonhouse M, Sokol GM, Trembath A, Weitkamp JH, Hornik CP. Opportunistic dried blood spot sampling validates and optimizes a pediatric population pharmacokinetic model of metronidazole. Antimicrob Agents Chemother 2024; 68:e0153323. [PMID: 38477706 PMCID: PMC10994817 DOI: 10.1128/aac.01533-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 02/16/2024] [Indexed: 03/14/2024] Open
Abstract
Pharmacokinetic models rarely undergo external validation in vulnerable populations such as critically ill infants, thereby limiting the accuracy, efficacy, and safety of model-informed dosing in real-world settings. Here, we describe an opportunistic approach using dried blood spots (DBS) to evaluate a population pharmacokinetic model of metronidazole in critically ill preterm infants of gestational age (GA) ≤31 weeks from the Metronidazole Pharmacokinetics in Premature Infants (PTN_METRO, NCT01222585) study. First, we used linear correlation to compare 42 paired DBS and plasma metronidazole concentrations from 21 preterm infants [mean (SD): post natal age 28.0 (21.7) days, GA 26.3 (2.4) weeks]. Using the resulting predictive equation, we estimated plasma metronidazole concentrations (ePlasma) from 399 DBS collected from 122 preterm and term infants [mean (SD): post natal age 16.7 (15.8) days, GA 31.4 (5.1) weeks] from the Antibiotic Safety in Infants with Complicated Intra-Abdominal Infections (SCAMP, NCT01994993) trial. When evaluating the PTN_METRO model using ePlasma from the SCAMP trial, we found that the model generally predicted ePlasma well in preterm infants with GA ≤31 weeks. When including ePlasma from term and preterm infants with GA >31 weeks, the model was optimized using a sigmoidal Emax maturation function of postmenstrual age on clearance and estimated the exponent of weight on volume of distribution. The optimized model supports existing dosing guidelines and adds new data to support a 6-hour dosing interval for infants with postmenstrual age >40 weeks. Using an opportunistic DBS to externally validate and optimize a metronidazole population pharmacokinetic model was feasible and useful in this vulnerable population.
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Affiliation(s)
- Rachel L. Randell
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Stephen J. Balevic
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Elizabeth J. Thompson
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Michael J. Smith
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Catherine Bendel
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Joseph M. Bliss
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Hala Chaaban
- Division of Neonatology, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rakesh Chhabra
- Division of Neonatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | | | - L. Corbin Downey
- Department of Pediatrics, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Chi Hornik
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Naveed Hussain
- Division of Neonatology, Department of Pediatrics, Connecticut Children’s, Hartford, Connecticut, USA
| | - Matthew M. Laughon
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Fernando Moya
- Division of Wilmington Pediatric Specialties, Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina, USA
| | - Matthew Saxonhouse
- Division of Neonatology, Department of Pediatrics, Levine Children’s Hospital, Wake Forest School of Medicine, Charlotte campus, Atrium Healthcare, Charlotte, North Carolina, USA
| | - Gregory M. Sokol
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrea Trembath
- Division of Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Joern-Hendrik Weitkamp
- Mildred Stahlman Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Best Pharmaceuticals for Children Act – Pediatric Trials Network Steering Committee
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
- Division of Neonatology, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
- Division of Neonatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack, New Jersey, USA
- Department of Pediatrics, Tufts Medical Center, Tufts University, Boston, Massachusetts, USA
- Department of Pediatrics, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
- Division of Neonatology, Department of Pediatrics, Connecticut Children’s, Hartford, Connecticut, USA
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Loma Linda University, Loma Linda, California, USA
- Division of Wilmington Pediatric Specialties, Department of Pediatrics, UNC School of Medicine, Chapel Hill, North Carolina, USA
- Division of Neonatology, Department of Pediatrics, Levine Children’s Hospital, Wake Forest School of Medicine, Charlotte campus, Atrium Healthcare, Charlotte, North Carolina, USA
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Division of Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Mildred Stahlman Division of Neonatology, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Velarde-Salcedo R, Pérez-González LF, Rodríguez-Báez AS, Arriaga-García FJ, Milán-Segovia RDC, Romano-Moreno S, Medellín-Garibay SE. Model-informed precision dosing of antimicrobial drugs in pediatrics: experiences from a pilot scale program. Eur J Pediatr 2023; 182:4143-4152. [PMID: 37436522 DOI: 10.1007/s00431-023-05103-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
Antibiotics are among the most utilized drugs in pediatrics. Nonetheless, there is a lack in pharmacokinetics information for this population, and dosing criteria may vary between healthcare centers. Physiological variability associated with maturation in pediatrics makes it challenging to reach a consensus on adequate dosing, which is further accentuated in more vulnerable groups, such as critically ill or oncology patients. Model-informed precision dosing is a useful practice that allows dose optimization and attainment of antibiotic-specific pharmacokinetic/pharmacodynamic targets. The aim of this study was to evaluate the needs of model-informed precision dosing of antibiotics in a pediatrics unit, at a pilot scale. Pediatric patients under antibiotic treatment were monitored with either a pharmacokinetic/pharmacodynamic optimized sampling scheme or through opportunistic sampling. Clindamycin, fluconazole, linezolid, meropenem, metronidazole, piperacillin, and vancomycin plasma concentrations were quantified through a liquid chromatography coupled to mass spectrometry method. Pharmacokinetic parameters were estimated using a Bayesian approach to verify pharmacokinetic/pharmacodynamic target attainment. A total of 23 pediatric patients aged 2 to 16 years were included, and 43 dosing regimens were evaluated; 27 (63%) of them required adjustments as follows: 14 patients were underdosed, 4 were overdosed, and 9 patients needed infusion rate adjustments. Infusion rate adjustments were mostly recommended for piperacillin and meropenem; daily doses were augmented for vancomycin and metronidazole, meanwhile linezolid was adjusted for under- and overdosing. Clindamycin and fluconazole regimens were not adjusted at all. Conclusion: Results showcase a lack of antibiotic pharmacokinetic/pharmacodynamic target attainment (particularly for linezolid, vancomycin, meropenem, and piperacillin), and the need for model-informed precision dosing in pediatrics. This study provides pharmacokinetic evidence which can further improve antibiotic dosing practices. What is Known: • Model-informed precision dosing is performed in pediatrics to optimize the treatment of antimicrobial drugs such as vancomycin and aminoglycosides, while its usefulness is debated for other groups (beta-lactams, macrolides, etc.). What is New: • Vulnerable pediatric subpopulations, such as critically ill or oncology patients, can benefit the most from model-informed precision dosing of antibiotics. • Model-informed precision dosing of linezolid, meropenem, piperacillin, and vancomycin is particularly useful in pediatrics, and further research may improve dosing practices altogether.
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Affiliation(s)
- Rodrigo Velarde-Salcedo
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, San Luis Potosí, S.L.P., México
| | | | | | | | | | - Silvia Romano-Moreno
- Facultad de Ciencias Químicas, Universidad Autónoma de San Luis Potosí, San Luis Potosí, S.L.P., México
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4
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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.
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5
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Commander SJ, Benjamin DK, Wu H, Thompson EJ, Lane M, Clark RH, Greenberg RG, Hornik CP. Exposure-response Relationships of Metronidazole in Infants: Integration of Electronic Health Record Data With Population Pharmacokinetic Modeling-derived Exposure Simulation. Pediatr Infect Dis J 2023; 42:27-31. [PMID: 36201670 PMCID: PMC9742159 DOI: 10.1097/inf.0000000000003726] [Citation(s) in RCA: 1] [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: 11/06/2022]
Abstract
BACKGROUND Infants frequently receive metronidazole at variable doses and duration for surgical site infection prophylaxis and treatment of intra-abdominal infections. Seizures are a rare (but potentially devastating) side effect of metronidazole, yet the prevalence of seizures in infants, as well as the relationship with metronidazole dose and exposure, are unknown. METHODS We examined the Pediatrix Clinical Data Warehouse for infants in neonatal intensive care units from 1997 to 2018 who received at least 1 dose of metronidazole during their first 120 days of life. We used an existing population pharmacokinetic model to simulate exposure parameters, estimating multivariable associations between metronidazole dosing and exposure parameters, and the occurrence of seizure. RESULTS There were 19,367 intravenous doses of metronidazole given to 1546 infants, and 31 experienced a seizure. Infants with a seizure had a longer median (interquartile values) duration of metronidazole exposure than those without (11 days [6, 15] vs. 7 [4, 11], P = 0.01). Each added day of metronidazole (OR = 1.06, 95% CI: 1.02-1.10), and each standard deviation increase in cumulative area under the plasma concentration-time curve (OR = 1.27, 95% CI: 1.11-1.45) were associated with increased odds of seizure. Higher simulated maximum plasma concentration was associated with lower odds of seizure (OR = 0.88, 95% CI: 0.81-0.96). CONCLUSIONS Longer metronidazole exposure and higher cumulative exposure could be associated with increased odds of infant seizures. Using a large observational dataset allowed us to identify a rare adverse event, but prospective studies are needed to validate this finding and further characterize metronidazole dose- and exposure-safety relationships.
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Affiliation(s)
- Sarah Jane Commander
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina
| | - Huali Wu
- Duke Clinical Research Institute, Durham, North Carolina
| | - Elizabeth J. Thompson
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina
| | - Morgan Lane
- Duke Clinical Research Institute, Durham, North Carolina
| | - Reese H. Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, Florida
| | - Rachel G. Greenberg
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina
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6
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Zhou J, Jiang L, Zhang ZL, Wang ZR, Zhang YX, Lin X, Tang BH, Yao BF, Guo ZX, Yang JJ, Van Den Anker J, Wu YE, Zhao W. Population pharmacokinetics and dosing optimization of mezlocillin in neonates and young infants. J Antimicrob Chemother 2022; 77:2238-2244. [PMID: 35662337 DOI: 10.1093/jac/dkac176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/07/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Mezlocillin is used in the treatment of neonatal infectious diseases. However, due to the absence of population pharmacokinetic studies in neonates and young infants, dosing regimens differ considerably in clinical practice. Hence, this study aimed to describe the pharmacokinetic characteristics of mezlocillin in neonates and young infants, and propose the optimal dosing regimen based on the population pharmacokinetic model of mezlocillin. METHODS A prospective, open-label pharmacokinetic study of mezlocillin was carried out in newborns. Blood samples were collected using an opportunistic sampling method. HPLC was used to measure the plasma drug concentrations. A population pharmacokinetic model was developed using NONMEM software. RESULTS Ninety-five blood samples from 48 neonates and young infants were included. The ranges of postmenstrual age and birth weight were 29-40 weeks and 1200-4000 g, respectively, including term and preterm infants. A two-compartment model with first-order elimination was developed to describe the population pharmacokinetics of mezlocillin. Postmenstrual age, current weight and serum creatinine concentration were the most important covariates. Monte Carlo simulation results indicated that the current dose of 50 mg/kg q12h resulted in 89.2% of patients achieving the therapeutic target, when the MIC of 4 mg/L was used as the breakpoint. When increasing the dosing frequency to q8h, a dose of 20 mg/kg resulted in 74.3% of patients achieving the therapeutic target. CONCLUSIONS A population pharmacokinetic model of mezlocillin in neonates and young infants was established. Optimal dosing regimens based on this model were provided for use in neonatal infections.
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Affiliation(s)
- Jing Zhou
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Pharmacy, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Li Jiang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Zhi-Ling Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Zhao-Rui Wang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Yan-Xiu Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Xu Lin
- Department of Pediatrics, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zi-Xuan Guo
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing-Jing Yang
- Department of Pharmacy, Qilu Hospital of Shandong University Dezhou Hospital, Dezhou, China
| | - John Van Den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA.,Departments of Pediatrics, Pharmacology & Physiology, Genomics and Precision Medicine, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA.,Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, University of Basel, Switzerland
| | - Yue-E Wu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.,NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drugs, Qilu Hospital of Shandong University, Shandong University, Jinan, China
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7
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Kennedy JL, Forrest JC, Young SG, Amick B, Williams M, James L, Snowden J, Cardenas VM, Boothe D, Kirkpatrick C, Modi Z, Caid K, Owens S, Kouassi M, Mann R, Putt C, Irish-Clardy K, Macechko M, Brimberry RK, Nembhard WN, McElfish PA, Du R, Jin J, Zohoori N, Kothari A, Hagrass H, Olgaard E, Boehme KW. Temporal Variations in Seroprevalence of SARS-CoV-2 Infections by Race and Ethnicity in Arkansas. Open Forum Infect Dis 2022; 9:ofac154. [PMID: 35493126 PMCID: PMC9045955 DOI: 10.1093/ofid/ofac154] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/22/2022] [Indexed: 01/19/2023] Open
Abstract
Background The aim of this study was to estimate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rates in the small rural state of Arkansas, using SARS-CoV-2 antibody prevalence as an indicator of infection. Methods We collected residual serum samples from adult outpatients seen at hospitals or clinics in Arkansas for non–coronavirus disease 2019 (COVID-19)–related reasons. A total of 5804 samples were identified over 3 time periods: 15 August–5 September 2020 (time period 1), 12 September–24 October 2020 (time period 2), and 7 November–19 December 2020 (time period 3). Results The age-, sex-, race-, and ethnicity-standardized SARS-CoV-2 seroprevalence during each period, from 2.6% in time period 1 to 4.1% in time period 2 and 7.4% in time period 3. No statistically significant difference in seroprevalence was found based on age, sex, or residence (urban vs rural). However, we found higher seroprevalence rates in each time period for Hispanics (17.6%, 20.6%, and 23.4%, respectively) and non-Hispanic Blacks (4.8%, 5.4%, and 8.9%, respectively) relative to non-Hispanic Whites (1.1%, 2.6%, and 5.5%, respectively). Conclusions Our data imply that the number of Arkansas residents infected with SARS-CoV-2 rose steadily from 2.6% in August to 7.4% in December 2020. There was no statistical difference in seroprevalence between rural and urban locales. Hispanics and Blacks had higher rates of SARS-CoV-2 antibodies than Whites, indicating that SARS-CoV-2 spread disproportionately in racial and ethnic minorities during the first year of the COVID-19 pandemic.
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Affiliation(s)
- Joshua L Kennedy
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Arkansas Children’s Research Institute, Little Rock, Arkansas, USA
| | - J Craig Forrest
- Department of Microbiology & Immunology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Center for Microbial Pathogenesis and Host Inflammatory Responses, Little Rock, Arkansas, USA
| | - Sean G Young
- Department of Environmental and Occupational Health, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Benjamin Amick
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mark Williams
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Laura James
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jessica Snowden
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Victor M Cardenas
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Danielle Boothe
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Zeel Modi
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Katherine Caid
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Shana Owens
- Department of Microbiology & Immunology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Marianne Kouassi
- Department of Microbiology & Immunology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ryan Mann
- Department of Microbiology & Immunology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Claire Putt
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Katherine Irish-Clardy
- Integrated Clinical Enterprise, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael Macechko
- Department of Family Medicine and Preventative Services, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ronald K Brimberry
- Department of Family Medicine and Preventative Services, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Wendy N Nembhard
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Pearl A McElfish
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ruofei Du
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jing Jin
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Namvar Zohoori
- Department of Epidemiology, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Arkansas Department of Health, Little Rock, Arkansas, USA
| | - Atul Kothari
- Department of Internal Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Arkansas Department of Health, Little Rock, Arkansas, USA
- Department of Bioinformatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hoda Hagrass
- Department of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Ericka Olgaard
- Department of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karl W Boehme
- Department of Microbiology & Immunology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Center for Microbial Pathogenesis and Host Inflammatory Responses, Little Rock, Arkansas, USA
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8
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Schouwenburg S, van der Klip RFJ, Smeets TJL, Hunfeld NGM, Flint RB, de Hoog M, Endeman H, Koch BCP, Wildschut ED, Abdulla A. Review of Scavenged Sampling for Sustainable Therapeutic Drug Monitoring: Do More With Less. Ther Drug Monit 2022; 44:215-223. [PMID: 34657093 PMCID: PMC8746914 DOI: 10.1097/ftd.0000000000000928] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Innovative and sustainable sampling strategies for bioanalytical quantification of drugs and metabolites have gained considerable interest. Scavenging can be stratified as a sustainable sampling strategy using residual material because it aligns with the green principles of waste reduction and sampling optimization. Scavenged sampling includes all biological fluids' (eg, blood, liquor, and urine) leftover from standard clinical care. This review elaborates on the past and current landscape of sustainable sampling within therapeutic drug monitoring, with a focus on scavenged sampling. METHODS In February 2021, 4 databases were searched to assess the literature on the clinical use of innovative and sustainable sampling techniques without applying publication date restrictions. Studies reporting the clinical use of scavenged blood sampling and bridging studies of scavenged sampling and normal blood sampling were eligible for inclusion. RESULTS Overall, 19 eligible studies concerning scavenged sampling were identified from 1441 records. Scavenged sampling is mainly applied in the pediatric population, although other patient groups may benefit from this strategy. The infrastructure required for scavenged sampling encounters several challenges, including logistic hurdles, storage and handling conditions, and documentation errors. A workflow is proposed with identified opportunities that guide the implementation of scavenged sampling. CONCLUSIONS This review presents current evidence on the clinical use of scavenged sampling strategies. Scavenged sampling can be a suitable approach for drug quantification to improve dosage regimens, perform pharmacokinetic studies, and explore the value of therapeutic drug monitoring without additional sample collection.
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Affiliation(s)
| | | | | | - Nicole G. M. Hunfeld
- Departments of Hospital Pharmacy and
- Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Robert B. Flint
- Departments of Hospital Pharmacy and
- Department of Pediatrics, Division of Neonatology, Erasmus MC—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands; and
| | - Matthijs de Hoog
- Department of Pediatric Intensive Care, Erasmus MC—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Henrik Endeman
- Adult Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Enno D. Wildschut
- Department of Pediatric Intensive Care, Erasmus MC—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Alan Abdulla
- Departments of Hospital Pharmacy and
- Department of Pediatric Intensive Care, Erasmus MC—Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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9
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Schouwenburg S, Wildschut ED, de Hoog M, Koch BCP, Abdulla A. The Pharmacokinetics of Beta-Lactam Antibiotics Using Scavenged Samples in Pediatric Intensive Care Patients: The EXPAT Kids Study Protocol. Front Pharmacol 2021; 12:750080. [PMID: 34955824 PMCID: PMC8703159 DOI: 10.3389/fphar.2021.750080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Emerging evidence supports the importance of optimized antibiotic exposure in pediatric intensive care unit (PICU) patients. Traditional antibiotic dosing is not designed for PICU patients, as the extreme pharmacokinetic (PK) behavior of drugs threatens the achievement of optimal antibiotic treatment outcomes. Scavenged sampling is a sampling strategy which may have positive implications for routine TDM and PK research, as well as monitoring other biomarkers. EXPAT Kids study was designed to analyze whether current empiric dosing regimens of frequently used beta-lactam antibiotics achieve defined therapeutic target concentrations in PICU patients. Methods: A mono-centre, exploratory pharmacokinetic and pharmacodynamic study was designed to assess target attainment of beta-lactam antibiotics. One hundred forty patients will be included within 24 months after start of inclusion. At various time points serum concentration of the study antibiotic (cefotaxime, ceftazidime, ceftriaxone, cefuroxime, flucloxacillin, and meropenem) are determined. In parallel with these sampling moments, residual material is collected to validate the use of blood of scavenged heparinized astrup syringes for the quantification of antibiotic exposure. The primary outcome is the time that the free (unbound) concentration of the study antibiotic remains above one to four the minimal inhibitory concentration during a dosing interval (100%ƒT > MIC and 100%ƒT>4xMIC). Other included outcomes are disease severity, safety, length of stay, and inflammatory biomarkers. Discussion: Potentially, scavenged sampling may enrich the EXPAT Kids dataset, and reduce additional blood sampling and workload for clinical personnel. The findings from the EXPAT Kids study will lead to new insights in the PK parameters of beta-lactams and consecutive effects on target attainment and clinical outcomes. Is there a need for more precision in dosing? Netherlands Trial Register Number: Trial NL9326.
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Affiliation(s)
- Stef Schouwenburg
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Enno D Wildschut
- Department of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - M de Hoog
- Department of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.,Department of Pediatric Intensive Care, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
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10
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Schleif W, Hamblin F, Everett AD, Graham EM, Cross J, Fernald C, Follett R, Lopes B, Martinez D, Monforte H, Ross-Wilkinson J, Sellers A, Brooks S. Tiny Bodies, Big Needs: Prospective Biobanking of Neonatal Clinical Remnant Samples. Biopreserv Biobank 2021; 19:106-110. [PMID: 33481645 DOI: 10.1089/bio.2020.0113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Repurposing biological samples collected for required diagnostic purposes into suitable biobanking projects is a particularly useful method for enabling research in vulnerable populations. This approach is especially appropriate for the neonate in the neonatal intensive care unit (NICU), where blood volume reductions can quickly increase beyond minimal risk for adverse events, such as iatrogenic anemia, and proxy consent provided by parents or guardians is required. The method described in this study provides a framework to prospectively collect and store blood-derived clinical samples after all clinical and regulatory requirements are fulfilled. The consent approach incorporated a 30-day window to allow parents and guardians ample consideration time with follow-up involvement with NICU embedded study team members. The study enrolled 875 participants over a 3-year period. This established a critically needed biobank to support investigator-initiated research with explicit study aims requiring samples at defined day of life frequencies within the NICU and created a normative control reference bank for case comparisons for premature and full-term neonates with brain injury.
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Affiliation(s)
- William Schleif
- Program in Pediatric Biospecimen Science, Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida, USA.,Johns Hopkins All Children's Pediatric Biorepository, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Frances Hamblin
- Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Allen D Everett
- Blalock-Taussig-Thomas Congenital Heart Center, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Ernest M Graham
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer Cross
- Johns Hopkins All Children's Pediatric Biorepository, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Christy Fernald
- Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Robert Follett
- Johns Hopkins All Children's Pediatric Biorepository, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Bryan Lopes
- Johns Hopkins All Children's Pediatric Biorepository, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Denise Martinez
- Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Hector Monforte
- Program in Pediatric Biospecimen Science, Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida, USA.,Johns Hopkins All Children's Pediatric Biorepository, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Jennifer Ross-Wilkinson
- Johns Hopkins All Children's Pediatric Biorepository, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Austin Sellers
- Johns Hopkins All Children's Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Sandra Brooks
- Johns Hopkins All Children's Maternal, Fetal, and Neonatal Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Division of Neonatology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
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11
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Commander SJ, Gao J, Zinkhan EK, Heresi G, Courtney SE, Lavery AP, Delmore P, Sokol GM, Moya F, Benjamin D, Bumpass TG, Debski J, Erinjeri J, Sharma G, Tracy ET, Smith PB, Cohen-Wolkowiez M, Hornik CP. Safety of Metronidazole in Late Pre-term and Term Infants with Complicated Intra-abdominal Infections. Pediatr Infect Dis J 2020; 39:e245-e248. [PMID: 32453198 PMCID: PMC10060863 DOI: 10.1097/inf.0000000000002698] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Metronidazole is frequently used off-label in infants with complicated intra-abdominal infections (cIAI) to provide coverage against anaerobic organisms, but its safety and efficacy in this indication are unknown. METHODS In the Antibiotic Safety in Infants with Complicated Intra-Abdominal Infections open-label multicenter trial infants ≥34 weeks gestation at birth and <121 days postnatal age with cIAIs were administered metronidazole as part of multimodal therapy. Metronidazole safety was evaluated by reporting of adverse events (AEs) and safety events of special interest. Cure from disease was determined by blood cultures and a clinical cure score >4. A blinded adjudication committee reviewed all safety events of special interest. RESULTS Fifty-five infants were included, median gestational age was 36 weeks (range: 34-41) and postnatal age was 7 days (0-63). The most common additional antibiotics received included gentamicin, piperacillin-tazobactam, ampicillin and vancomycin. Only one AE, a candidal rash, was identified to be potentially caused by metronidazole administration. One infant died of cardiopulmonary failure, which was deemed unrelated to metronidazole. The most common events of special interest included feeding intolerance in 18 (33%) infants, and exploratory laparotomy in 10 (18%) requiring intestinal anastomosis in 7 (13%) infants. There was 1 (2%) intestinal stricture. Fifty-three infants (96%) achieved overall therapeutic success, 54 (98%) were alive through 30 days post-study therapy, and 54 (98%) had 30-day clinical cure score >4. CONCLUSIONS In a cohort of late pre-term and term infants with cIAIs, combination antibiotic therapy that included metronidazole was safe, and therapeutic success was high.
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Affiliation(s)
- Sarah Jane Commander
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jamie Gao
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Erin K Zinkhan
- Department of Pediatrics, Division of Neonatology, Intermountain Medical Center, University of Utah, Salt Lake City, Utah
| | - Gloria Heresi
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Texas, Houston, Texas
| | - Sherry E Courtney
- Department of Pediatrics, Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Adrian P Lavery
- Department of Pediatrics, Division of Neonatology, Loma Linda University, Loma Linda, California
| | - Paula Delmore
- Department of Pediatrics, Wichita Medical Research and Education Foundation, Wichita, Kansas
| | - Gregory M Sokol
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Fernando Moya
- Department of Pediatrics, Coastal Carolina Neonatology, Wilmington, North Carolina
| | - Danny Benjamin
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Tedryl G Bumpass
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Elisabeth T Tracy
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - P Brian Smith
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Christoph P Hornik
- Department of Pediatrics, Division of Pediatric Research, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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12
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The Utility of Pharmacometric Models in Clinical Pharmacology Research in Infants. ACTA ACUST UNITED AC 2020; 6:260-266. [PMID: 33767946 DOI: 10.1007/s40495-020-00234-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Purpose of commentary Acquiring knowledge on drug disposition and action in infant is challenging because of the problem of sparse and unbalanced data obtained for each individual infant due to the limited blood volume as well as the issue of extensive inter-subject and intra-subject variability in drug exposure and response due to the fast growth and dynamic maturation changes in infants. This commentary highlights the importance of using population-based pharmacometric models to improve knowledge on drug disposition and action in infants. Recent findings Pharmacometric modeling remains to be critical in clinical pharmacology research in infants. Many pediatric covariate models developed for scaling of drug clearance use a combination of allometric weight scaling to account for size change and a sigmoid function of antenatal development and postnatal maturation to characterize the age-related maturation. To expedite the development of safe and effective dosing regimens in infants, a number of strategies have been proposed recently, including the use of pediatric covariate model obtained from one drug for extrapolation to other drugs undergoing similar elimination pathways, as well as the combination of opportunistic clinical studies and population-based pharmacometrics models. Summary Population-based pharmacometric modeling plays a pivotal role in clinical pharmacology research in infants. Most of the covariate models reported so far focus on antibiotics undergoing renal elimination. Novel modeling strategies have been proposed recently to facilitate clinical pharmacology research and expedite the dose optimization process in infants.
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13
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Le J, Bradley JS. Optimizing Antibiotic Drug Therapy in Pediatrics: Current State and Future Needs. J Clin Pharmacol 2019; 58 Suppl 10:S108-S122. [PMID: 30248202 DOI: 10.1002/jcph.1128] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/01/2018] [Indexed: 12/19/2022]
Abstract
The selection of the right antibiotic and right dose necessitates clinicians understand the contribution of pharmacokinetic variability stemming from age-related physiologic maturation and the pharmacodynamics to optimize drug exposure for clinical response. The complexity of selecting the right dose arises from the multiplicity of pediatric age groups, from premature neonates to adolescents. Body size and age (which relate to organ function) must be incorporated to optimize antibiotic dosing in this vulnerable population. In the effort to optimize and individualize drug dosing regimens, clinical pharmacometrics that incorporate population-based pharmacokinetic modeling, Bayesian estimation, and Monte Carlo simulations are utilized as a quantitative approach to understanding and predicting the pharmacology and clinical and microbiologic efficacy of antibiotics. In addition, opportunistic study designs and alternative blood sampling strategies can serve as practical approaches to ensure successful conduct of pediatric studies. This review article examines relevant literature on optimization of antibiotic pharmacotherapy in pediatric populations published within the last decade. Specific pediatric antibiotic data, including beta-lactam antibiotics, aminoglycosides, and vancomycin, are critically evaluated.
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Affiliation(s)
- Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, La Jolla, CA, USA
| | - John S Bradley
- Department of Pediatrics, Division of Infectious Diseases, University of California at San Diego, La Jolla, CA, USA.,Rady Children's Hospital San Diego, San Diego, CA, USA
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14
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Child J, Chen X, Mistry RD, Somme S, MacBrayne C, Anderson PL, Jones RN, Parker SK. Pharmacokinetic and Pharmacodynamic Properties of Metronidazole in Pediatric Patients With Acute Appendicitis: A Prospective Study. J Pediatric Infect Dis Soc 2019; 8:297-302. [PMID: 29788329 DOI: 10.1093/jpids/piy040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 04/24/2018] [Indexed: 11/14/2022]
Abstract
BACKGROUND Metronidazole is traditionally dosed every 6-8 hours even though in adults it has a long half-life, concentration-dependent killing, and 3-hour postantibiotic effect. Based on this logic, some pediatric hospitals adopted once-daily dosing for appendicitis, despite limited pharmacokinetics-pharmacodynamics (PK/PD) in children. We studied pediatric patients with appendicitis given metronidazole once daily to determine whether this dosing would meet target area under the curve (AUC)/minimum inhibitory concentration (MIC) ratio of ≥70 for Bacteroides fragilis. METHODS One hundred pediatric patients aged 4-17 years had an average of 3 blood draws per patient during the first 24 hours after a 30 mg/kg per dose of intravenous metronidazole. Concentrations of drug were determined using validated liquid chromatography and tandem mass spectrometry. A NONMEM model was constructed for determining PK, followed by Monte Carlo simulations to generate a population of plasma concentration-time AUC of metronidazole and hydroxy-metronidazole. RESULTS Simulated AUC values met target attainment (AUC/MIC ratio of ≥70 to B fragilis MICs) for 96%-100% of all patients for an MIC of 2 mcg/mL. For MICs of 4 and 8 mcg/mL, target attainment ranged from 61% to 97% and 9% to 71%, respectively. Areas under the curve were similar to that of adults receiving 1000 mg and 1500 mg q24, or 500 mg q8 hours. CONCLUSIONS Metronidazole, 30 mg/kg per dose, once daily achieved AUC target attainment for B fragilis with an MIC of 2 mcg/mL or less in pediatric appendicitis patients. Based on this and studies in adults, there does not seem to be any PK/PD advantage of more frequent dosing in this population.
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Affiliation(s)
- Jason Child
- Department of Pharmacy, Children's Hospital Colorado, Aurora
| | - Xinhui Chen
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Stig Somme
- Division of General, Thoracic, and Fetal Pediatric Surgery, Department of Pediatrics, Children's Hospital Colorado, Aurora
| | - Christine MacBrayne
- Department of Pharmacy, Children's Hospital Colorado, Aurora.,University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | - Peter L Anderson
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| | | | - Sarah K Parker
- Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, Aurora
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15
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Standing JF, Ongas MO, Ogwang C, Kagwanja N, Murunga S, Mwaringa S, Ali R, Mturi N, Timbwa M, Manyasi C, Mwalekwa L, Bandika VL, Ogutu B, Waichungo J, Kipper K, Berkley JA. Dosing of Ceftriaxone and Metronidazole for Children With Severe Acute Malnutrition. Clin Pharmacol Ther 2018; 104:1165-1174. [PMID: 29574688 PMCID: PMC6282491 DOI: 10.1002/cpt.1078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 03/15/2018] [Accepted: 03/18/2018] [Indexed: 12/12/2022]
Abstract
Infants and young children with severe acute malnutrition (SAM) are treated with empiric broad-spectrum antimicrobials. Parenteral ceftriaxone is currently a second-line agent for invasive infection. Oral metronidazole principally targets small intestinal bacterial overgrowth. Children with SAM may have altered drug absorption, distribution, metabolism, and elimination. Population pharmacokinetics of ceftriaxone and metronidazole were studied, with the aim of recommending optimal dosing. Eighty-one patients with SAM (aged 2-45 months) provided 234 postdose pharmacokinetic samples for total ceftriaxone, metronidazole, and hydroxymetronidazole. Ceftriaxone protein binding was also measured in 190 of these samples. A three-compartment model adequately described free ceftriaxone, with a Michaelis-Menten model for concentration and albumin-dependent protein binding. A one-compartment model was used for both metronidazole and hydroxymetronidazole, with only 1% of hydroxymetronidazole predicted to be formed during first-pass. Simulations showed 80 mg/kg once daily of ceftriaxone and 12.5 mg/kg twice daily of metronidazole were sufficient to reach therapeutic targets.
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Affiliation(s)
- Joseph F. Standing
- Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
- Paediatric Infectious Diseases Research GroupInstitute for Infection and Immunity, St. George's, University of LondonLondonUK
| | - Martin O. Ongas
- Center for Research in Therapeutic SciencesStrathmore UniversityNairobiKenya
- KEMRI‐Centre for Clinical ResearchNairobiKenya
| | | | | | | | | | - Rehema Ali
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Neema Mturi
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
| | - Moline Timbwa
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Mbagathi County HospitalNairobiKenya
| | - Christine Manyasi
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Mbagathi County HospitalNairobiKenya
| | - Laura Mwalekwa
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- Coast General HospitalMombasaKenya
| | | | - Bernhards Ogutu
- Center for Research in Therapeutic SciencesStrathmore UniversityNairobiKenya
- KEMRI‐Centre for Clinical ResearchNairobiKenya
| | | | - Karin Kipper
- Analytical Services International, St George's University of LondonLondonUK
- Institute of ChemistryUniversity of TartuTartuEstonia
| | - James A. Berkley
- KEMRI‐Wellcome Trust Research ProgrammeKilifiKenya
- The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of MedicineUniversity of OxfordOxfordUK
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16
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Balevic SJ, Cohen-Wolkowiez M. Innovative Study Designs Optimizing Clinical Pharmacology Research in Infants and Children. J Clin Pharmacol 2018; 58 Suppl 10:S58-S72. [PMID: 30248192 PMCID: PMC6310922 DOI: 10.1002/jcph.1053] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/07/2017] [Indexed: 12/16/2022]
Abstract
Almost half of recent pediatric trials failed to achieve labeling indications, in large part because of inadequate study design. Therefore, innovative study methods are crucial to optimizing trial design while also reducing the potential harms inherent with drug investigation. Several methods exist to optimize the amount of pharmacokinetic data collected from the smallest possible volume and with the fewest number of procedures, including the use of opportunistic and sparse sampling, alternative and noninvasive matrices, and microvolume assays. In addition, large research networks using master protocols promote collaboration, reduce regulatory burden, and increase trial efficiency for both early- and late-phase trials. Large pragmatic trials that leverage electronic health records can capitalize on central management strategies to reduce costs, enroll patients with rare diseases on a large scale, and augment study generalizability. Further, trial efficiency and safety can be optimized through Bayesian adaptive techniques that permit planned protocol changes based on analyses of prior and accumulated data. In addition to these trial design features, advances in modeling and simulation have paved the way for systems-based and physiologically based models that individualize pediatric dosing recommendations and support drug approval. Last, given the low prevalence of many pediatric diseases, collecting deidentified genetic and clinical data on a large scale is a potentially transformative way to augment clinical pharmacology research in children.
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Affiliation(s)
- Stephen J. Balevic
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
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17
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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
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18
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Penetration of Cefotaxime into Cerebrospinal Fluid in Neonates and Young Infants. Antimicrob Agents Chemother 2018; 62:AAC.02448-17. [PMID: 29437625 DOI: 10.1128/aac.02448-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/31/2018] [Indexed: 01/11/2023] Open
Abstract
Cefotaxime is the first-line treatment for meningitis in neonates and young infants. However, limited data on cefotaxime cerebrospinal fluid (CSF) concentrations in neonates and young infants were available. The aim of the present study was to evaluate the penetration of cefotaxime into CSF in neonates and young infants. Blood and CSF samples were collected from neonates and young infants treated with cefotaxime using an opportunistic pharmacokinetic sampling strategy, and concentrations were quantified by high-performance liquid chromatography-tandem mass spectrometry. The analysis was performed using NONMEM and R software. Thirty neonates and young infants (postmenstrual age range, 25.4 to 47.4 weeks) were included. A total of 67 plasma samples and 30 CSF samples were available for analysis. Cefotaxime plasma and CSF concentrations ranged from 2.30 to 175.42 mg/liter and from 0.39 to 25.38 mg/liter, respectively. The median ratio of the CSF concentration to the plasma concentration was 0.28 (range, 0.06 to 0.76). Monte Carlo simulation demonstrated that 88.4% and 63.9% of hypothetical neonates treated with 50 mg/kg of body weight three times a day (TID) would reach the pharmacodynamic target (the percentage of the dosing interval that the free antimicrobial drug concentration remains above the MIC, 70%) using the standard EUCAST MIC susceptibility breakpoints of 2 mg/liter and 4 mg/liter, respectively. The penetration of cefotaxime into the CSF of neonates and young infants was evaluated using an opportunistic sampling approach. A dosage regimen of 50 mg/kg TID could cover the most causative pathogens with MICs of <2 mg/liter. Individual dosage adaptation was required for more resistant bacterial strains, such as Staphylococcus aureus.
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Le J, Poindexter B, Sullivan JE, Laughon M, Delmore P, Blackford M, Yogev R, James LP, Melloni C, Harper B, Mitchell J, Benjamin DK, Boakye-Agyeman F, Cohen-Wolkowiez M. Comparative Analysis of Ampicillin Plasma and Dried Blood Spot Pharmacokinetics in Neonates. Ther Drug Monit 2018; 40:103-108. [PMID: 29271816 PMCID: PMC5764797 DOI: 10.1097/ftd.0000000000000466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dried blood spot (DBS) is a practical sampling strategy for pharmacokinetic studies in neonates. The utility of DBS to determine the population pharmacokinetics (pop-PK) of ampicillin, as well as accuracy versus plasma samples, was evaluated. METHODS An open-label, multicenter, opportunistic, prospective study was conducted in neonates. Ampicillin concentrations from plasma and DBS (CONCPlasma and CONCDBS) were measured by liquid chromatographic tandem mass spectrometry and analyzed using pop-PK and statistical (including transformation) approaches. RESULTS A total of 29 paired plasma and DBS samples from 18 neonates were analyzed. The median (range) gestational age and postnatal age were 37 (27-41) weeks and 8 (1-26) days, respectively. The geometric mean of CONCDBS to CONCPlasma ratio was 0.56. Correlation analysis demonstrated strong association between CONCPlasma and CONCDBS (r = 0.902, analysis of variance P < 0.001). Using linear regression transformation, the estimated CONCPlasma (eCONCPlasma) was derived using (CONCDBS - 3.223)/0.51. The median bias and geometric mean ratio improved to -11% and 0.88 (Wilcoxon signed-rank test, P < 0.001), respectively, when comparing eCONCPlasma to CONCPlasma. Furthermore, using pop-PK modeling, the median bias (interquartile range) for clearance and individual predicted concentrations improved to 8% (-11 to 50) and -8% (-34 to 11), respectively, when eCONCPlasma was used. CONCLUSIONS After transformation, DBS sampling accurately predicted ampicillin exposure in neonates.
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Affiliation(s)
- Jennifer Le
- University of California, San Diego, Skaggs School of Pharmacy, CA
| | - Brenda Poindexter
- Indiana University School of Medicine, Indianapolis, IN, and Cincinnati Children's, Cincinnati, OH
| | - Janice E. Sullivan
- University of Louisville, Norton Children's Hospital and Kosair Charities Pediatric Clinical Research Unit, Louisville, KY
| | - Matthew Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Ram Yogev
- Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Laura P. James
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital at Little Rock, Little Rock, AR
| | - Chiara Melloni
- Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | | | - Daniel K. Benjamin
- Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Felix Boakye-Agyeman
- Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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Development of a Novel Multipenicillin Assay and Assessment of the Impact of Analyte Degradation: Lessons for Scavenged Sampling in Antimicrobial Pharmacokinetic Study Design. Antimicrob Agents Chemother 2017; 62:AAC.01540-17. [PMID: 29084754 DOI: 10.1128/aac.01540-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/24/2017] [Indexed: 11/20/2022] Open
Abstract
Penicillins are widely used to treat infections in children; however, the evidence is continuing to evolve in defining the optimal dosing. Modern pediatric pharmacokinetic study protocols frequently favor opportunistic, "scavenged" sampling. This study aimed to develop a small-volume single assay for five major penicillins and to assess the influence of sample degradation on inferences made using pharmacokinetic modeling, to investigate the suitability of scavenged sampling strategies. Using a rapid ultrahigh-performance liquid chromatographic-tandem mass spectrometric method, an assay for five penicillins (amoxicillin, ampicillin, benzylpenicillin, piperacillin, and flucloxacillin) in blood plasma was developed and validated. Penicillin stabilities were evaluated under different conditions. Using these data, the impact of drug degradation on inferences made during pharmacokinetic modeling was evaluated. All evaluated penicillins indicated good stability at room temperature (23 ± 2°C) over 1 h, remaining in the range of 98 to 103% of the original concentration. More-rapid analyte degradation had already occurred after 4 h, with stability ranging from 68% to 99%. Stability over longer periods declined: degradation of up to 60% was observed with delayed sample processing of up to 24 h. Modeling showed that analyte degradation can lead to a 30% and 28% bias in clearance and volume of distribution, respectively, and falsely show nonlinearity in clearance. Five common penicillins can now be measured in a single low-volume blood sample. Beta-lactam chemical instability in plasma can cause misleading pharmacokinetic modeling results, which could impact upon model-based dosing recommendations and the forthcoming era of beta-lactam therapeutic drug monitoring.
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Hornik CP, Wu H, Edginton AN, Watt K, Cohen-Wolkowiez M, Gonzalez D. Development of a Pediatric Physiologically-Based Pharmacokinetic Model of Clindamycin Using Opportunistic Pharmacokinetic Data. Clin Pharmacokinet 2017; 56:1343-1353. [PMID: 28290120 PMCID: PMC5597447 DOI: 10.1007/s40262-017-0525-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Physiologically-based pharmacokinetic (PBPK) modeling is a powerful tool used to characterize maturational changes in drug disposition to inform dosing across childhood; however, its use is limited in pediatric drug development. Access to pediatric pharmacokinetic data is a barrier to widespread application of this model, which impedes its development and optimization. To support the development of a pediatric PBPK model, we sought to leverage opportunistically-collected plasma concentrations of the commonly used antibiotic clindamycin. The pediatric PBPK model was optimized following development of an adult PBPK model that adequately described literature data. We evaluated the predictability of the pediatric population PBPK model across four age groups and found that 63-93% of the observed data were captured within the 90% prediction interval of the model. We then used the pediatric PBPK model to optimize intravenous clindamycin dosing for a future prospective validation trial. The optimal dosing proposed by this model was 9 mg/kg/dose in children ≤5 months of age, 12 mg/kg/dose in children >5 months-6 years of age, and 10 mg/kg/dose in children 6-18 years of age, all administered every 8 h. The simulated exposures achieved with the dosing regimen proposed were comparable with adult plasma and tissue exposures for the treatment of community-acquired methicillin-resistant Staphylococcus aureus infections. Our model demonstrated the feasibility of using opportunistic pediatric data to develop pediatric PBPK models, extending the reach of this powerful modeling tool and potentially transforming the pediatric drug development field.
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Affiliation(s)
- 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.
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Kevin Watt
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, 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
| | - Daniel Gonzalez
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Rivera-Chaparro ND, Cohen-Wolkowiez M, Greenberg RG. Dosing antibiotics in neonates: review of the pharmacokinetic data. Future Microbiol 2017; 12:1001-1016. [PMID: 28758800 PMCID: PMC5627030 DOI: 10.2217/fmb-2017-0058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 05/23/2017] [Indexed: 12/20/2022] Open
Abstract
Antibiotics are often used in neonates despite the absence of relevant dosing information in drug labels. For neonatal dosing, clinicians must extrapolate data from studies for adults and older children, who have strikingly different physiologies. As a result, dosing extrapolation can lead to increased toxicity or efficacy failures in neonates. Driven by these differences and recent legislation mandating the study of drugs in children and neonates, an increasing number of pharmacokinetic studies of antibiotics are being performed in neonates. These studies have led to new dosing recommendations with particular consideration for neonate body size and maturation. Herein, we highlight the available pharmacokinetic data for commonly used systemic antibiotics in neonates.
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Affiliation(s)
- Nazario D Rivera-Chaparro
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
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Korosh T, Bujans E, Morada M, Karaalioglu C, Vanden Eynde JJ, Mayence A, Huang TL, Yarlett N. Potential of bisbenzimidazole-analogs toward metronidazole-resistant Trichomonas vaginalis
isolates. Chem Biol Drug Des 2017; 90:489-495. [DOI: 10.1111/cbdd.12972] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Travis Korosh
- Department of Chemistry and Physical Sciences; Pace University; New York NY USA
- Haskins Laboratories; Pace University; New York NY USA
| | - Emmanuel Bujans
- Department of Chemistry and Physical Sciences; Pace University; New York NY USA
- Haskins Laboratories; Pace University; New York NY USA
| | - Mary Morada
- Haskins Laboratories; Pace University; New York NY USA
| | - Canan Karaalioglu
- Department of Chemistry and Physical Sciences; Pace University; New York NY USA
| | - Jean Jacques Vanden Eynde
- Division of Basic Pharmaceutical Sciences; College of Pharmacy; Xavier University of Louisiana; New Orleans LA USA
| | - Annie Mayence
- Division of Basic Pharmaceutical Sciences; College of Pharmacy; Xavier University of Louisiana; New Orleans LA USA
| | - Tien L. Huang
- Division of Basic Pharmaceutical Sciences; College of Pharmacy; Xavier University of Louisiana; New Orleans LA USA
| | - Nigel Yarlett
- Department of Chemistry and Physical Sciences; Pace University; New York NY USA
- Haskins Laboratories; Pace University; New York NY USA
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Leroux S, Turner MA, Guellec CBL, Hill H, van den Anker JN, Kearns GL, Jacqz-Aigrain E, Zhao W. Pharmacokinetic Studies in Neonates: The Utility of an Opportunistic Sampling Design. Clin Pharmacokinet 2016; 54:1273-85. [PMID: 26063050 DOI: 10.1007/s40262-015-0291-1] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE The use of an opportunistic (also called scavenged) sampling strategy in a prospective pharmacokinetic study combined with population pharmacokinetic modelling has been proposed as an alternative strategy to conventional methods for accomplishing pharmacokinetic studies in neonates. However, the reliability of this approach in this particular paediatric population has not been evaluated. The objective of the present study was to evaluate the performance of an opportunistic sampling strategy for a population pharmacokinetic estimation, as well as dose prediction, and compare this strategy with a predetermined pharmacokinetic sampling approach. METHODS Three population pharmacokinetic models were derived for ciprofloxacin from opportunistic blood samples (SC model), predetermined (i.e. scheduled) samples (TR model) and all samples (full model used to previously characterize ciprofloxacin pharmacokinetics), using NONMEM software. The predictive performance of developed models was evaluated in an independent group of patients. RESULTS Pharmacokinetic data from 60 newborns were obtained with a total of 430 samples available for analysis; 265 collected at predetermined times and 165 that were scavenged from those obtained as part of clinical care. All datasets were fit using a two-compartment model with first-order elimination. The SC model could identify the most significant covariates and provided reasonable estimates of population pharmacokinetic parameters (clearance and steady-state volume of distribution) compared with the TR and full models. Their predictive performances were further confirmed in an external validation by Bayesian estimation, and showed similar results. Monte Carlo simulation based on area under the concentration-time curve from zero to 24 h (AUC24)/minimum inhibitory concentration (MIC) using either the SC or the TR model gave similar dose prediction for ciprofloxacin. CONCLUSION Blood samples scavenged in the course of caring for neonates can be used to estimate ciprofloxacin pharmacokinetic parameters and therapeutic dose requirements.
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Affiliation(s)
- Stéphanie Leroux
- Sino-French Pediatric Research Center, Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, 44 West Wenhua Road, 250012, Jinan, China
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France
- EA7323, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Department of Neonatology, CHU de Rennes, Rennes, France
| | - Mark A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Neonatal Unit, Liverpool Women's Hospital, Liverpool, UK
| | | | - Helen Hill
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
- Neonatal Unit, Liverpool Women's Hospital, Liverpool, UK
| | - Johannes N van den Anker
- Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
- Division of Pediatric Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA
- Departments of Pediatrics, Pharmacology and Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
- Department of Paediatric Pharmacology, University Children's Hospital Basel, Basel, Switzerland
| | - Gregory L Kearns
- Division of Clinical Pharmacology and Therapeutic Innovation, the Children's Mercy Hospital, Kansas City, MO, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Evelyne Jacqz-Aigrain
- Sino-French Pediatric Research Center, Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, 44 West Wenhua Road, 250012, Jinan, China
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France
- EA7323, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Clinical Investigation Center CIC1426, INSERM, Paris, France
| | - Wei Zhao
- Sino-French Pediatric Research Center, Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, 44 West Wenhua Road, 250012, Jinan, China.
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.
- EA7323, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
- Clinical Investigation Center CIC1426, INSERM, Paris, France.
- Department of Pharmacy, Qianfoshan Hospital Affiliated to Shandong University, Jian, China.
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25
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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]
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Thakkar N, Gonzalez D, Cohen-Wolkowiez M, Massaro M, Bernhardt J, Zane NR, Laughon MM. An opportunistic study evaluating pharmacokinetics of sildenafil for the treatment of pulmonary hypertension in infants. J Perinatol 2016; 36:744-7. [PMID: 27171763 PMCID: PMC5002251 DOI: 10.1038/jp.2016.79] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 03/23/2016] [Accepted: 04/01/2016] [Indexed: 12/02/2022]
Abstract
OBJECTIVE The objective of this study is to assess sildenafil and N-desmethyl sildenafil (DMS) exposure in infants receiving sildenafil for the treatment of pulmonary hypertension (PH). STUDY DESIGN Data were collected from six infants receiving sildenafil for the treatment of PH and plasma samples were collected at the time of routine laboratory blood draws. The echocardiography results were assessed for improvement in right ventricular (RV) hypertension following sildenafil treatment. RESULT The median (range) sildenafil and DMS concentrations were 27.4 ng ml(-1) (2.6 to 434.0) and 105.5 ng ml(-1) (3.6 to 314.0), respectively. The median metabolite-to-parent ratio was higher in infants receiving co-medications that can induce cytochrome P450 (CYP) enzymes (5.2 vs 0.7). The echocardiography results showed improvement in RV hypertension for the majority of infants (5/6). CONCLUSION The concentrations of sildenafil and DMS were within the previously observed ranges. Our results suggest that caution may be warranted when CYP-related co-medications are administered during sildenafil treatment for PH.
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Affiliation(s)
- Nilay Thakkar
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, 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
| | - 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
| | - Matthew Massaro
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Janice Bernhardt
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nicole R. Zane
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew M. Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Momper JD, Capparelli EV, Wade KC, Kantak A, Dhanireddy R, Cummings JJ, Nedrelow JH, Hudak ML, Mundakel GT, Natarajan G, Gao J, Laughon M, Smith PB, Benjamin DK. Population Pharmacokinetics of Fluconazole in Premature Infants with Birth Weights Less than 750 Grams. Antimicrob Agents Chemother 2016; 60:5539-45. [PMID: 27401564 PMCID: PMC4997840 DOI: 10.1128/aac.00963-16] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 06/28/2016] [Indexed: 11/20/2022] Open
Abstract
Fluconazole is an effective agent for prophylaxis of invasive candidiasis in premature infants. The objective of this study was to characterize the population pharmacokinetics (PK) and dosing requirements of fluconazole in infants with birth weights of <750 g. As part of a randomized clinical trial, infants born at <750 g birth weight received intravenous (i.v.) or oral fluconazole at 6 mg/kg of body weight twice weekly. Fluconazole plasma concentrations from samples obtained by either scheduled or scavenged sampling were measured using a liquid chromatography-tandem mass spectrometry assay. Population PK analysis was conducted using NONMEM 7.2. Population PK parameters were allometrically scaled by body weight. Covariates were evaluated by univariable screening followed by multivariable assessment. Fluconazole exposures were simulated in premature infants using the final PK model. A population PK model was developed from 141 infants using 604 plasma samples. Plasma fluconazole PK were best described by a one-compartment model with first-order elimination. Only serum creatinine was an independent predictor for clearance in the final model. The typical population parameter estimate for oral bioavailability in the final model was 99.5%. Scavenged samples did not bias the parameter estimates and were as informative as scheduled samples. Simulations indicated that the study dose maintained fluconazole troughs of >2,000 ng/ml in 80% of simulated infants at week 1 and 59% at week 4 of treatment. Developmental changes in fluconazole clearance are best predicted by serum creatinine in this population. A twice-weekly dose of 6 mg/kg achieves appropriate levels for prevention of invasive candidiasis in extremely premature infants.
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Affiliation(s)
| | | | - Kelly C Wade
- Children's Hospital of Philadelphia, Pennsylvania, USA
| | - Anand Kantak
- Children's Hospital Medical Center of Akron, Akron, Ohio, USA
| | | | - James J Cummings
- East Carolina University, Brody School of Medicine, Greenville, North Carolina, USA
| | | | - Mark L Hudak
- University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | | | - Jamie Gao
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Matt Laughon
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P Brian Smith
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
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Author's Reply to Standing et al. Pharmacokinetic Studies in Neonates: The Utility of an Opportunistic Sampling Design. Clin Pharmacokinet 2016; 54:1289-91. [PMID: 26547310 DOI: 10.1007/s40262-015-0341-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Dorofaeff T, Bandini RM, Lipman J, Ballot DE, Roberts JA, Parker SL. Uncertainty in Antibiotic Dosing in Critically Ill Neonate and Pediatric Patients: Can Microsampling Provide the Answers? Clin Ther 2016; 38:1961-75. [PMID: 27544661 DOI: 10.1016/j.clinthera.2016.07.093] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/20/2016] [Accepted: 07/22/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE With a decreasing supply of antibiotics that are effective against the pathogens that cause sepsis, it is critical that we learn to use currently available antibiotics optimally. Pharmacokinetic studies provide an evidence base from which we can optimize antibiotic dosing. However, these studies are challenging in critically ill neonate and pediatric patients due to the small blood volumes and associated risks and burden to the patient from taking blood. We investigate whether microsampling, that is, obtaining a biologic sample of low volume (<50 μL), can improve opportunities to conduct pharmacokinetic studies. METHODS We performed a literature search to find relevant articles using the following search terms: sepsis, critically ill, severe infection, intensive care AND antibiotic, pharmacokinetic, p(a)ediatric, neonate. For microsampling, we performed a search using antibiotics AND dried blood spots OR dried plasma spots OR volumetric absorptive microsampling OR solid-phase microextraction OR capillary microsampling OR microsampling. Databases searched include Web of Knowledge, PubMed, and EMbase. FINDINGS Of the 32 antibiotic pharmacokinetic studies performed on critically ill neonate or pediatric patients in this review, most of the authors identified changes to the pharmacokinetic properties in their patient group and recommended either further investigations into this patient population or therapeutic drug monitoring to ensure antibiotic doses are suitable. There remain considerable gaps in knowledge regarding the pharmacokinetic properties of antibiotics in critically ill pediatric patients. Implementing microsampling in an antibiotic pharmacokinetic study is contingent on the properties of the antibiotic, the pathophysiology of the patient (and how this can affect the microsample), and the location of the patient. A validation of the sampling technique is required before implementation. IMPLICATIONS Current antibiotic regimens for critically ill neonate and pediatric patients are frequently suboptimal due to a poor understanding of altered pharmacokinetic properties. An assessment of the suitability of microsampling for pharmacokinetic studies in neonate and pediatric patients is recommended before wider use. The method of sampling, as well as the method of bioanalysis, also requires validation to ensure the data obtained reflect the true result.
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Affiliation(s)
- Tavey Dorofaeff
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Paediatric Intensive Care, Lady Cilento Children's Hospital, Brisbane, Australia
| | - Rossella M Bandini
- School of Physiology, University of the Witwatersrand, Johannesburg, South Africa; Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa
| | - Jeffrey Lipman
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa; Department of Intensive Care Medicine, Royal Brisbane Hospital, Brisbane, Australia; Faculty of Health, Brisbane, Queensland University of Technology, Brisbane, Australia
| | - Daynia E Ballot
- Wits UQ Critical Care Infection Collaboration, Johannesburg, South Africa; Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jason A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia; Department of Intensive Care Medicine, Royal Brisbane Hospital, Brisbane, Australia; Department of Pharmacy, Royal Brisbane Hospital, Brisbane, Australia; School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Suzanne L Parker
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia.
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Van Driest SL, Marshall MD, Hachey B, Beck C, Crum K, Owen J, Smith AH, Kannankeril PJ, Woodworth A, Caprioli RM, Choi L. Pragmatic pharmacology: population pharmacokinetic analysis of fentanyl using remnant samples from children after cardiac surgery. Br J Clin Pharmacol 2016; 81:1165-74. [PMID: 26861166 DOI: 10.1111/bcp.12903] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/29/2016] [Accepted: 02/03/2016] [Indexed: 12/25/2022] Open
Abstract
AIMS One barrier contributing to the lack of pharmacokinetic (PK) data in paediatric populations is the need for serial sampling. Analysis of clinically obtained specimens and data may overcome this barrier. To add evidence for the feasibility of this approach, we sought to determine PK parameters for fentanyl in children after cardiac surgery using specimens and data generated in the course of clinical care, without collecting additional blood samples. METHODS We measured fentanyl concentrations in plasma from leftover clinically-obtained specimens in 130 paediatric cardiac surgery patients and successfully generated a PK dataset using drug dosing data extracted from electronic medical records. Using a population PK approach, we estimated PK parameters for this population, assessed model goodness-of-fit and internal model validation, and performed subset data analyses. Through simulation studies, we compared predicted fentanyl concentrations using model-driven weight-adjusted per kg vs. fixed per kg fentanyl dosing. RESULTS Fentanyl clearance for a 6.4 kg child, the median weight in our cohort, is 5.7 l h(-1) (2.2-9.2 l h(-1) ), similar to values found in prior formal PK studies. Model assessment and subset analyses indicated the model adequately fit the data. Of the covariates studied, only weight significantly impacted fentanyl kinetics, but substantial inter-individual variability remained. In simulation studies, model-driven weight-adjusted per kg fentanyl dosing led to more consistent therapeutic fentanyl concentrations than fixed per kg dosing. CONCLUSIONS We show here that population PK modelling using sparse remnant samples and electronic medical records data provides a powerful tool for assessment of drug kinetics and generation of individualized dosing regimens.
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Affiliation(s)
- Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew D Marshall
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brian Hachey
- Department of Biochemistry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cole Beck
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kim Crum
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jill Owen
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew H Smith
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alison Woodworth
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Richard M Caprioli
- Department of Biochemistry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
PURPOSE OF REVIEW Antibiotics have not only saved lives and improved outcomes, but they also influence the evolving microbiome. This review summarizes reports on neonatal infections and variation in antibiotic utilization, discusses the emergence of resistant organisms, and presents data from human neonates and animal models demonstrating the impact of antibiotics on the microbiome, and how microbiome alterations impact health. The importance of antibiotic stewardship is also discussed. RECENT FINDINGS Infections increase neonatal morbidity and mortality. Furthermore, the clinical presentation of infections can be subtle, prompting clinicians to empirically start antibiotics when infection is a possibility. Antibiotic-resistant infections are a growing problem. Cohort studies have identified extensive center variations in antibiotic usage and associations between antibiotic exposures and outcomes. Studies of antibiotic-induced microbiome alterations and downstream effects on the developing immune system have increased our understanding of the mechanisms underlying the associations between antibiotics and adverse outcomes. The emergence of resistant microorganisms and recent evidence linking antibiotic practice variations with health outcomes has led to the initiation of antibiotic stewardship programs. SUMMARY The review encourages practitioners to assess local antibiotic use with regard to local microbiology, and to adopt steps to reduce infections and use antibiotics wisely.
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England A, Wade K, Smith PB, Berezny K, Laughon M. Optimizing operational efficiencies in early phase trials: The Pediatric Trials Network experience. Contemp Clin Trials 2016; 47:376-82. [PMID: 26968616 PMCID: PMC4997801 DOI: 10.1016/j.cct.2016.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 01/09/2023]
Abstract
Performing drug trials in pediatrics is challenging. In support of the Best Pharmaceuticals for Children Act, the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the formation of the Pediatric Trials Network (PTN) in 2010. Since its inception, the PTN has developed strategies to increase both efficiency and safety of pediatric drug trials. Through use of innovative techniques such as sparse and scavenged blood sampling as well as opportunistic study design, participation in trials has grown. The PTN has also strived to improve consistency of adverse event reporting in neonatal drug trials through the development of a standardized adverse event table. We review how the PTN is optimizing operational efficiencies in pediatric drug trials to increase the safety of drugs in children.
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Affiliation(s)
- Amanda England
- Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, N.C. Memorial Hospital, 101 Manning Drive, CB#7596, Chapel Hill, NC 27599-7596, USA
| | - Kelly Wade
- Division of Neonatology, Children's Hospital of Pennsylvania, CHOP Newborn Care at the Hospital of the University of Pennsylvania, 800 Spruce St., Philadelphia, PA 19107, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA; Duke Clinical Research Institute, Duke University School of Medicine, P.O. Box 17969, Durham, NC 27715, USA
| | - Katherine Berezny
- Duke Clinical Research Institute, Duke University School of Medicine, P.O. Box 17969, Durham, NC 27715, USA
| | - Matthew Laughon
- Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, N.C. Memorial Hospital, 101 Manning Drive, CB#7596, Chapel Hill, NC 27599-7596, USA.
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Pandya HC, Mulla H, Hubbard M, Cordell RL, Monks PS, Yakkundi S, McElnay JC, Nunn AJ, Turner MA. Essential medicines containing ethanol elevate blood acetaldehyde concentrations in neonates. Eur J Pediatr 2016; 175:841-7. [PMID: 26997167 PMCID: PMC4868857 DOI: 10.1007/s00431-016-2714-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/03/2016] [Accepted: 03/08/2016] [Indexed: 01/15/2023]
Abstract
UNLABELLED Neonates administered ethanol-containing medicines are potentially at risk of dose-dependent injury through exposure to ethanol and its metabolite, acetaldehyde. Here, we determine blood ethanol and acetaldehyde concentrations in 49 preterm infants (median birth weight = 1190 g) dosed with iron or furosemide, medicines that contain different amounts of ethanol, and in 11 control group infants (median birth weight = 1920 g) who were not on any medications. Median ethanol concentrations in neonates administered iron or furosemide were 0.33 (range = 0-4.92) mg/L, 0.39 (range = 0-72.77) mg/L and in control group infants were 0.15 (range = 0.03-5.4) mg/L. Median acetaldehyde concentrations in neonates administered iron or furosemide were 0.16 (range = 0-8.89) mg/L, 0.21 (range = 0-2.43) mg/L and in control group infants were 0.01 (range = 0-0.14) mg/L. There was no discernible relationship between blood ethanol or acetaldehyde concentrations and time after medication dose. CONCLUSION Although infants dosed with iron or furosemide had low blood ethanol concentrations, blood acetaldehyde concentrations were consistent with moderate alcohol exposure. The data suggest the need to account for the effects of acetaldehyde in the benefit-risk analysis of administering ethanol-containing medicines to neonates. WHAT IS KNOWN • Neonates are commonly treated with ethanol-containing medicines, such as iron and furosemide. • However, there is no data on whether this leads to appreciable increases in blood concentrations of ethanol or its metabolite, acetaldehyde. What is New: • In this study, we find low blood ethanol concentrations in neonates administered iron and/or furosemide but markedly elevated blood acetaldehyde concentrations in some infants receiving these medicines. • Our data suggest that ethanol in drugs may cause elevation of blood acetaldehyde, a potentially toxic metabolite.
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Affiliation(s)
- H. C. Pandya
- />Department of Infection, Immunity and Inflammation, University of Leicester, University Road, Leicester, LE1 9HN UK
| | - H. Mulla
- />Department of Pharmacy, University of Hospitals Leicester NHS Trust, Leicester, UK
| | - M. Hubbard
- />Neonatal Unit University of Hospitals Leicester NHS Trust, Leicester, UK
| | - R. L. Cordell
- />Department of Chemistry, University of Leicester, Leicester, UK
| | - P. S. Monks
- />Department of Chemistry, University of Leicester, Leicester, UK
| | - S. Yakkundi
- />Department of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - J. C. McElnay
- />Department of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - A. J. Nunn
- />Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - M. A. Turner
- />Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Turner MA. Clinical trials of medicines in neonates: the influence of ethical and practical issues on design and conduct. Br J Clin Pharmacol 2015; 79:370-8. [PMID: 25041601 DOI: 10.1111/bcp.12467] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 06/24/2014] [Indexed: 01/03/2023] Open
Abstract
In the past, there has been a perception that ethical and practical problems limit the opportunities for research in neonates. This perception is no longer appropriate. It is now clear that research about the medicines used in neonates is an ethical requirement. It is possible to conduct high quality research in neonates if the research team adapt to the characteristics of this population. Good practice involves respecting the specific needs of newborn babies and their families by adopting relevant approaches to study design, recruitment, pharmacokinetic studies and safety assessment. Neonatal units have a unique culture that requires careful development in a research setting. Clinical investigators need to recognize the clinical and ethical imperative to conduct rigorous research. Industry needs to engage with neonatal networks early in the process of drug development, preferably before contacting regulatory agencies. Follow-up over 3-5 years is essential for the evaluation of medicines in neonates and explicit funding for this is required for the assessment of the benefit and risk of treatments given to sick newborn babies. The views of parents must be central to the development of studies and the research agenda. Ethical and practical problems are no longer barriers to research in neonates. The current challenges are to disseminate good practice and maximize capacity in order to meet the need for research among newborn babies.
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Affiliation(s)
- Mark A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Zhao W, Zhang D, Storme T, Baruchel A, Declèves X, Jacqz-Aigrain E. Population pharmacokinetics and dosing optimization of teicoplanin in children with malignant haematological disease. Br J Clin Pharmacol 2015; 80:1197-207. [PMID: 26138279 DOI: 10.1111/bcp.12710] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/17/2015] [Accepted: 06/28/2015] [Indexed: 12/22/2022] Open
Abstract
AIM Children with haematological malignancy represent an identified subgroup of the paediatric population with specific pharmacokinetic parameters. In these patients, inadequate empirical antibacterial therapy may result in infection-related morbidity and increased mortality, making optimization of the dosing regimen essential. As paediatric data are limited, our aim was to evaluate the population pharmacokinetics of teicoplanin in order to define the appropriate dosing regimen in this high risk population. METHODS The current dose of teicoplanin was evaluated in children with haematological malignancy. Population pharmacokinetics of teicoplanin were analyzed using nonmem software. The dosing regimen was optimized based on the final model. RESULTS Eighty-five children (age range 0.5 to 16.9 years) were included. Therapeutic drug monitoring and opportunistic samples (n = 143) were available for analysis. With the current recommended dose of 10 mg kg(-1) day(-1) , 41 children (48%) had sub-therapeutic steady-state trough concentrations (Css,min <10 mg l(-1) ). A two compartment pharmacokinetic model with first order elimination was developed. Systematic covariate analysis identified that bodyweight (size) and creatinine clearance significantly influenced teicoplanin clearance. The model was validated internally. Its predictive performance was further confirmed in an external validation. In order to reach the target AUC of 750 mg l(-1) h 18 mg kg(-1) was required for infants, 14 mg kg(-1) for children and 12 mg kg(-1) for adolescents. A patient-tailored dose regimen was further developed and reduced variability in AUC and Css,min values compared with the mg kg(-1) basis dose, making the modelling approach an important tool for dosing individualization. CONCLUSIONS This first population pharmacokinetic study of teicoplanin in children with haematological malignancy provided evidence-based support to individualize teicoplanin therapy in this vulnerable population.
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Affiliation(s)
- Wei Zhao
- Sino-French Pediatric Research Center, Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan.,Department of Pharmacy, Qianfoshan Hospital Affiliated to Shandong University, Shandong University, Jinan, China.,Department of Paediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris.,Clinical Investigation Center CIC1426, INSERM, Paris
| | - Daolun Zhang
- Department of Paediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris
| | - Thomas Storme
- Department of Pharmacy, Hôpital Robert Debré, APHP, Paris
| | - André Baruchel
- Department of Paediatric Haemato-Oncology, Hôpital Robert Debré, APHP, Paris
| | - Xavier Declèves
- Department of Pharmacokinetics and Pharmacochemistry, Hôpital Cochin, APHP, Paris, France
| | - Evelyne Jacqz-Aigrain
- Sino-French Pediatric Research Center, Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan.,Department of Paediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris.,Clinical Investigation Center CIC1426, INSERM, Paris
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Wang J, Edginton AN, Avant D, Burckart GJ. Predicting neonatal pharmacokinetics from prior data using population pharmacokinetic modeling. J Clin Pharmacol 2015; 55:1175-83. [PMID: 25907280 DOI: 10.1002/jcph.524] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 04/19/2015] [Indexed: 11/08/2022]
Abstract
Selection of the first dose for neonates in clinical trials is very challenging. The objective of this analysis was to assess if a population pharmacokinetic (PK) model developed with data from infants to adults is predictive of neonatal clearance and to evaluate what age range of prior PK data is needed for informative modeling to predict neonate exposure. Two sources of pharmacokinetic data from 8 drugs were used to develop population models: (1) data from all patients > 2 years of age, and (2) data from all nonneonatal patients aged > 28 days. The prediction error based on the models using data from subjects > 2 years of age showed bias toward overprediction, with median average fold error (AFE) for CL predicted/CLobserved greater than 1.5. The bias for predicting neonatal PK was improved when using all prior PK data including infants as opposed to an assessment without infant PK data, with the median AFE 0.91. As an increased number of pediatric trials are conducted in neonates under the Food and Drug Administration Safety and Innovation Act, dose selection should be based on the best estimates of neonatal pharmacokinetics and pharmacodynamics prior to conducting efficacy and safety studies in neonates.
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Affiliation(s)
- Jian Wang
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | | | - Debbie Avant
- Office of Pediatric Therapeutics, Commissioner's Office, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Gilbert J Burckart
- Pediatric Clinical Pharmacology Staff, Office of Clinical Pharmacology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
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Leroux S, Zhao W, Bétrémieux P, Pladys P, Saliba E, Jacqz-Aigrain E. Therapeutic guidelines for prescribing antibiotics in neonates should be evidence-based: a French national survey. Arch Dis Child 2015; 100:394-8. [PMID: 25628457 DOI: 10.1136/archdischild-2014-306873] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This survey aims to describe and analyse the dosage regimens of antibiotics in French neonatal intensive care units (NICUs). METHODS Senior doctors from 56 French NICUs were contacted by telephone and/or email to provide their local guidelines for antibiotic therapy. RESULTS 44 (79%) NICUs agreed to participate in this survey. In total, 444 dosage regimens were identified in French NICUs for 41 antibiotics. The number of different dosage regimens varied from 1 to 32 per drug (mean 9, SD 7.8). 37% of intravenous dosage regimens used a unique mg/kg dose from preterm to full-term neonates. Doses and/or dosing intervals varied significantly for 12 antibiotics (amikacin, gentamicin, netilmicin, tobramycin, vancomycin administered as continuous infusion, ceftazidime, cloxacillin, oxacillin, penicillin G, imipenem/cilastatin, clindamycin and metronidazole). Among these antibiotics, 6 were used in more than 70% of local guidelines and had significant variations in (1) maintenance daily doses for amikacin, imipenem/cilastatin, ceftazidime and metronidazole; (2) loading doses for continuous infusion of vancomycin; and (3) dosing intervals for gentamicin and amikacin. CONCLUSIONS A considerable inter-centre variability of dosage regimens of antibiotics exists in French NICUs. Developmental pharmacokinetic-pharmacodynamic studies are essential for the evaluation of antibiotics in order to establish evidence-based dosage regimens for effective and safe administration in neonates.
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Affiliation(s)
- Stéphanie Leroux
- Department of Paediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France EA7323, Université Paris Diderot-Université Paris Descartes, Paris, France Division of Neonatology, Department of Child and Adolescent Medicine, CHU de Rennes, Rennes, France
| | - Wei Zhao
- Department of Paediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France EA7323, Université Paris Diderot-Université Paris Descartes, Paris, France Clinical Investigation Center CIC1426, INSERM, Paris, France Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Pierre Bétrémieux
- Division of Neonatology, Department of Child and Adolescent Medicine, CHU de Rennes, Rennes, France
| | - Patrick Pladys
- Division of Neonatology, Department of Child and Adolescent Medicine, CHU de Rennes, Rennes, France INSERM U1099, Institut des Neurosciences Cliniques de Rennes, Rennes, France
| | - Elie Saliba
- Paediatric and Neonatal Intensive Care Unit, CHRU Tours, Tours, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France EA7323, Université Paris Diderot-Université Paris Descartes, Paris, France Clinical Investigation Center CIC1426, INSERM, Paris, France
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Batchelor HK, Marriott JF. Paediatric pharmacokinetics: key considerations. Br J Clin Pharmacol 2015; 79:395-404. [PMID: 25855821 PMCID: PMC4345950 DOI: 10.1111/bcp.12267] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 10/17/2013] [Indexed: 12/12/2022] Open
Abstract
A number of anatomical and physiological factors determine the pharmacokinetic profile of a drug. Differences in physiology in paediatric populations compared with adults can influence the concentration of drug within the plasma or tissue. Healthcare professionals need to be aware of anatomical and physiological changes that affect pharmacokinetic profiles of drugs to understand consequences of dose adjustments in infants and children. Pharmacokinetic clinical trials in children are complicated owing to the limitations on blood sample volumes and perception of pain in children resulting from blood sampling. There are alternative sampling techniques that can minimize the invasive nature of such trials. Population based models can also limit the sampling required from each individual by increasing the overall sample size to generate robust pharmacokinetic data. This review details key considerations in the design and development of paediatric pharmacokinetic clinical trials.
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Affiliation(s)
- Hannah Katharine Batchelor
- Pharmacy, Pharmacology and Therapeutics, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of BirminghamMedical School Building, Edgbaston, B15 2TT, UK
| | - John Francis Marriott
- Pharmacy, Pharmacology and Therapeutics, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of BirminghamMedical School Building, Edgbaston, B15 2TT, UK
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Abstract
To prevent the devastating consequences of infection, most infants admitted to the neonatal intensive care unit are exposed to antibiotics. However, dosing regimens are often extrapolated from data in adults and older children, increasing the risk for drug toxicity and lack of clinical efficacy because they fail to account for developmental changes in infant physiology. However, newer technologies are emerging with minimal-risk study designs, including ultra-low-volume assays, pharmacokinetic modeling and simulation, and opportunistic drug protocols. With minimal-risk study designs, pharmacokinetic data and dosing regimens for infants are now available for ampicillin, clindamycin, meropenem, metronidazole, and piperacillin/tazobactam.
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Affiliation(s)
| | - Kevin M. Watt
- Department of Pediatrics, Duke University, Durham, NC,Duke Clinical Research Institute, Durham, NC
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40
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Ku LC, Smith PB. Dosing in neonates: special considerations in physiology and trial design. Pediatr Res 2015; 77:2-9. [PMID: 25268145 PMCID: PMC4268272 DOI: 10.1038/pr.2014.143] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 06/13/2014] [Indexed: 01/11/2023]
Abstract
Determining the right dose for drugs used to treat neonates is critically important. Neonates have significant differences in physiology affecting drug absorption, distribution, metabolism, and elimination that make extrapolating dosages from adults and older children inappropriate. In spite of recent legislative efforts requiring drug studies in this population, most drugs given to neonates remain insufficiently studied. Many ethical and logistical concerns make designing studies in this age group difficult. Fortunately, specialized analytical techniques, such as the use of dried blood spots, scavenged sampling, population pharmacokinetics analyses, and sparse sampling, have helped investigators better define doses that maximize efficacy and safety. Through the use of these methods, successful clinical trials have resulted in recent changes to drug dosing in this population.
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Affiliation(s)
- Lawrence C. Ku
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Gonzalez D, Melloni C, Yogev R, Poindexter BB, Mendley SR, Delmore P, Sullivan JE, Autmizguine J, Lewandowski A, Harper B, Watt KM, Lewis KC, Capparelli EV, Benjamin DK, Cohen-Wolkowiez M. Use of opportunistic clinical data and a population pharmacokinetic model to support dosing of clindamycin for premature infants to adolescents. Clin Pharmacol Ther 2014; 96:429-37. [PMID: 24949994 PMCID: PMC4169790 DOI: 10.1038/clpt.2014.134] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 06/13/2014] [Indexed: 11/08/2022]
Abstract
Clindamycin is commonly prescribed to treat children with skin and skin-structure infections (including those caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA)), yet little is known about its pharmacokinetics (PK) across pediatric age groups. A population PK analysis was performed in NONMEM using samples collected in an opportunistic study from children receiving i.v. clindamycin per standard of care. The final model was used to optimize pediatric dosing to match adult exposure proven effective against CA-MRSA. A total of 194 plasma PK samples collected from 125 children were included in the analysis. A one-compartment model described the data well. The final model included body weight and a sigmoidal maturation relationship between postmenstrual age (PMA) and clearance (CL): CL (l/h) = 13.7 × (weight/70)(0.75) × (PMA(3.1)/(43.6(3.1) + PMA(3.1))); V (l) = 61.8 × (weight/70). Maturation reached 50% of adult CL values at ~44 weeks PMA. Our findings support age-based dosing.
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Ram Yogev
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Brenda B. Poindexter
- Department of Pediatrics, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Susan R. Mendley
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
| | - Paula Delmore
- Department of Pediatrics, Wesley Medical Center, Wichita, KS
| | - Janice E. Sullivan
- Kosair Charities Pediatric Clinical Research Unit, Department of Pediatrics, University of Louisville, Louisville, KY
| | - Julie Autmizguine
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | | | - Barrie Harper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Kevin M. Watt
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | | | | | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
- Department of Pediatrics, Duke University Medical Center, Durham, NC
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Gonzalez D, Paul IM, Benjamin DK, Cohen-Wolkowiez M. Advances in pediatric pharmacology, therapeutics, and toxicology. Adv Pediatr 2014; 61:7-31. [PMID: 25037123 PMCID: PMC4120955 DOI: 10.1016/j.yapd.2014.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In the United States, passage of the FDASIA legislation made BPCA and PREA permanent, no longer requiring reauthorization every 5 years. This landmark legislation also stressed the importance of performing clinical trials in neonates when appropriate. In Europe the Pediatric Regulation, which went into effect in early 2007, also provides a framework for expanding pediatric clinical research. Although much work remains, as a result of greater regulatory guidance more pediatric data are reaching product labels.
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Affiliation(s)
- Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 301 Pharmacy Lane, Chapel Hill, NC 27599, USA; Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA
| | - Ian M Paul
- Department of Pediatrics, College of Medicine, Penn State University, 500 University Drive, HS83, Hershey, PA 17033, USA; Department of Public Health Sciences, College of Medicine, Penn State University, 500 University Drive, HS83, Hershey, PA 17033, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, College of Medicine, Duke University, T901/Children's Health Center, Durham, NC 27705, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA; Department of Pediatrics, College of Medicine, Duke University, T901/Children's Health Center, Durham, NC 27705, USA.
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Barker CIS, Germovsek E, Hoare RL, Lestner JM, Lewis J, Standing JF. Pharmacokinetic/pharmacodynamic modelling approaches in paediatric infectious diseases and immunology. Adv Drug Deliv Rev 2014; 73:127-39. [PMID: 24440429 PMCID: PMC4076844 DOI: 10.1016/j.addr.2014.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 12/09/2013] [Accepted: 01/11/2014] [Indexed: 02/02/2023]
Abstract
Pharmacokinetic/pharmacodynamic (PKPD) modelling is used to describe and quantify dose-concentration-effect relationships. Within paediatric studies in infectious diseases and immunology these methods are often applied to developing guidance on appropriate dosing. In this paper, an introduction to the field of PKPD modelling is given, followed by a review of the PKPD studies that have been undertaken in paediatric infectious diseases and immunology. The main focus is on identifying the methodological approaches used to define the PKPD relationship in these studies. The major findings were that most studies of infectious diseases have developed a PK model and then used simulations to define a dose recommendation based on a pre-defined PD target, which may have been defined in adults or in vitro. For immunological studies much of the modelling has focused on either PK or PD, and since multiple drugs are usually used, delineating the relative contributions of each is challenging. The use of dynamical modelling of in vitro antibacterial studies, and paediatric HIV mechanistic PD models linked with the PK of all drugs, are emerging methods that should enhance PKPD-based recommendations in the future.
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Affiliation(s)
- Charlotte I S Barker
- Paediatric Infectious Diseases Research Group, Division of Clinical Sciences, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK; Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK
| | - Eva Germovsek
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK
| | - Rollo L Hoare
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK; CoMPLEX, University College London, Physics Building, Gower Street, London WC1E 6BT, UK
| | - Jodi M Lestner
- Paediatric Infectious Diseases Research Group, Division of Clinical Sciences, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Joanna Lewis
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK; CoMPLEX, University College London, Physics Building, Gower Street, London WC1E 6BT, UK
| | - Joseph F Standing
- Infectious Diseases and Microbiology Unit, University College London, Institute of Child Health, London WC1N 1EH, UK; CoMPLEX, University College London, Physics Building, Gower Street, London WC1E 6BT, UK.
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Cohen-Wolkowiez M, Watt KM, Zhou C, Bloom BT, Poindexter B, Castro L, Gao J, Capparelli EV, Benjamin DK, Smith PB. Developmental pharmacokinetics of piperacillin and tazobactam using plasma and dried blood spots from infants. Antimicrob Agents Chemother 2014; 58:2856-65. [PMID: 24614369 PMCID: PMC3993246 DOI: 10.1128/aac.02139-13] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 03/01/2014] [Indexed: 02/07/2023] Open
Abstract
Piperacillin-tazobactam is often given to infants with severe infection in spite of limited pharmacokinetics (PK) data. We evaluated piperacillin-tazobactam PK in premature and term infants of ages <61 days with suspected systemic infection. Infants received intravenous piperacillin-tazobactam (80 to 100 mg/kg of body weight every 8 h [q 8 h]) based on gestational and postnatal age. Sparse plasma samples were obtained after first and multiple doses. Drug concentrations were measured by tandem mass spectrometry. PK data were analyzed using population nonlinear mixed-effect modeling. Target attainment rates for the time unbound piperacillin concentrations remained above the MIC for 50% and 75% of the dosing interval at steady state were evaluated. Bias in population PK parameter estimates was assessed for dried blood spot (DBS) samples, and a comparability analysis was performed for DBS and plasma drug concentrations using linear regression. We obtained 128 plasma samples from 32 infants, median gestational age of 30 weeks (range, 23 to 40 weeks) and postnatal age of 8 days (range, 1 to 60). Piperacillin and tazobactam PK models included body weight (WT) and postmenstrual age (PMA) as covariates for clearance and WT for volume of distribution and were used to optimize dosing in infants. DBS drug concentrations were 50 to 60% lower than those in plasma, but when combined with plasma concentrations and a matrix effect, the data generated PK model parameters similar to those for plasma alone. With PMA-based dosing (100 mg/kg q 8 h, 80 mg/kg q 6 h, and 80 mg/kg q 4 h for PMA of ≤30, 30 to 35, and 35 to 49 weeks, respectively), 90% of simulated infants achieved the surrogate therapeutic target of time above the MIC (≤32 mg/liter) for 75% of the dosing interval.
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Affiliation(s)
- Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kevin M. Watt
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Chenguang Zhou
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Barry T. Bloom
- Wichita Medical Research and Education Foundation, Wichita, Kansas, USA
| | | | - Lisa Castro
- Overland Park Regional Medical Center, Overland Park, Kansas, USA
| | - Jamie Gao
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Edmund V. Capparelli
- Department of Pediatric Pharmacology, University of California, San Diego, California, USA
| | - Daniel K. Benjamin
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P. Brian Smith
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Himebauch AS, Zuppa A. Methods for pharmacokinetic analysis in young children. Expert Opin Drug Metab Toxicol 2014; 10:497-509. [DOI: 10.1517/17425255.2014.885502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Determining population and developmental pharmacokinetics of metronidazole using plasma and dried blood spot samples from premature infants. Pediatr Infect Dis J 2013; 32:956-61. [PMID: 23587979 PMCID: PMC3769518 DOI: 10.1097/inf.0b013e3182947cf8] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Limited pharmacokinetic (PK) data of metronidazole in premature infants have led to various dosing recommendations. Surrogate efficacy targets for metronidazole are ill-defined and therefore aimed to exceed minimum inhibitory concentration of organisms responsible for intra-abdominal infections. METHODS We evaluated the PK of metronidazole using plasma and dried blood spot samples from infants ≤32 weeks gestational age in an open-label, PK, multicenter (N = 3) study using population PK modeling (NONMEM). Monte Carlo simulations (N = 1000 virtual subjects) were used to evaluate the surrogate efficacy target. Metabolic ratios of parent and metabolite were calculated. RESULTS Twenty-four premature infants (111 plasma and 51 dried blood spot samples) were enrolled: median (range) gestational age at birth 25 (23-31) weeks, postnatal age 27 (1-82) days, postmenstrual age 31 (24-39) weeks and weight 740 (431-1466) g. Population clearance (L/h/kg) was 0.038 × (postmenstrual age/30) and volume of distribution (L/kg) of 0.93. PK parameter estimates and precision were similar between plasma and dried blood spot samples. Metabolic ratios correlated with clearance. CONCLUSION Simulations suggested the majority of infants in the neonatal intensive care unit (>80%) would meet the surrogate efficacy target using postmenstrual age-based dosing.
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Pearce RE, Cohen-Wolkowiez M, Sampson MR, Kearns GL. The role of human cytochrome P450 enzymes in the formation of 2-hydroxymetronidazole: CYP2A6 is the high affinity (low Km) catalyst. Drug Metab Dispos 2013; 41:1686-94. [PMID: 23813797 DOI: 10.1124/dmd.113.052548] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Despite metronidazole's widespread clinical use since the 1960s, the specific enzymes involved in its biotransformation have not been previously identified. Hence, in vitro studies were conducted to identify and characterize the cytochrome P450 enzymes involved in the formation of the major metabolite, 2-hydroxymetronidazole. Formation of 2-hydroxymetronidazole in human liver microsomes was consistent with biphasic, Michaelis-Menten kinetics. Although several cDNA-expressed P450 enzymes catalyzed 2-hydroxymetronidazole formation at a supratherapeutic concentration of metronidazole (2000 μM), at a "therapeutic concentration" of 100 μM only CYPs 2A6, 3A4, 3A5, and 3A7 catalyzed metronidazole 2-hydroxylation at rates substantially greater than control vector, and CYP2A6 catalyzed 2-hydroxymetronidazole formation at rates 6-fold higher than the next most active enzyme. Kinetic studies with these recombinant enzymes revealed that CYP2A6 has a Km = 289 μM which is comparable to the Km for the high-affinity (low-Km) enzyme in human liver microsomes, whereas the Km values for the CYP3A enzymes corresponded with the low-affinity (high-Km) component. The sample-to-sample variation in 2-hydroxymetronidazole formation correlated significantly with CYP2A6 activity (r ≥ 0.970, P < 0.001) at substrate concentrations of 100 and 300 μM. Selective chemical inhibitors of CYP2A6 inhibited metronidazole 2-hydroxylation in a concentration-dependent manner and inhibitory antibodies against CYP2A6 virtually eliminated metronidazole 2-hydroxylation (>99%). Chemical and antibody inhibitors of other P450 enzymes had little or no effect on metronidazole 2-hydroxylation. These results suggest that CYP2A6 is the primary catalyst responsible for the 2-hydroxylation of metronidazole, a reaction that may function as a marker of CYP2A6 activity both in vitro and in vivo.
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Affiliation(s)
- Robin E Pearce
- Section of Developmental Pharmacology and Experimental Therapeutics, Division of Pediatric Clinical Pharmacology and Therapeutic Innovation, The Children's Mercy Hospitals, Kansas City, MO 64108, USA.
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Population pharmacokinetics of piperacillin using scavenged samples from preterm infants. Ther Drug Monit 2013; 34:312-9. [PMID: 22569355 DOI: 10.1097/ftd.0b013e3182587665] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Piperacillin is often used in preterm infants for intra-abdominal infections; however, dosing has been derived from small single-center studies excluding extremely preterm infants at a highest risk for these infections. We evaluated the population pharmacokinetics (PK) of piperacillin using targeted sparse sampling and scavenged samples obtained from preterm infants ≤ 32 weeks of gestational age at birth and <120 postnatal days. MATERIALS AND METHODS A 5-center study was performed. A population PK model using nonlinear mixed effect modeling was developed. Covariate effects were evaluated based on the estimated precision and clinical significance. RESULTS Fifty-six preterm infants were evaluated and had a median (range) gestational age at birth of 25 (22-32) weeks, a postnatal age of 17 (1-77) days, a postmenstrual age of 29 (23-40) weeks, and a weight of 867 (400-2580) g. The final PK data set contained 211 samples; 202/211 (96%) were scavenged from the discarded clinical specimens. Piperacillin population PK was best described by a 1-compartment model. The population mean clearance (CL) was derived by the equation CL (L/h) = 0.479 × (weight)(0.75) × 0.5/serum creatinine and using a volume of distribution (V) (L) of 2.91 × (weight). The relative standard errors around parameter estimates ranged from 13.7% to 32.2%. A trend toward increased CL was observed with increasing gestational age at birth; infants with serum creatinine ≥ 1.2 mg/dL had a 60% reduction in piperacillin CL. The majority (>70%) of infants did not meet predefined pharmacodynamic efficacy targets. CONCLUSIONS Scavenged PK sampling is a minimal-risk approach that can provide meaningful information related to the development of PK models but not dosing recommendations for piperacillin. The utility of scavenged sampling in providing definitive dosing recommendations may be drug dependent and needs to be further explored.
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Bai JPF, Barrett JS, Burckart GJ, Meibohm B, Sachs HC, Yao L. Strategic biomarkers for drug development in treating rare diseases and diseases in neonates and infants. AAPS JOURNAL 2013; 15:447-54. [PMID: 23334978 DOI: 10.1208/s12248-013-9452-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 01/04/2013] [Indexed: 12/11/2022]
Abstract
There are similar challenges in developing a product designed to treat patients with a rare disease and drugs to treat critically ill neonates and infants. Part of the challenge in developing such products as well as identifying the optimal dosing regimen for the treatment of young children arises from the complex interrelationship between developmental changes and changes in biomarkers responsive to drug therapy. These difficulties are further compounded by our lack of understanding of the key physiological factors that cause the differences in clinical responses between adults and neonates and infants. Regulatory efforts have succeeded in overcoming these challenges in many areas of pediatric and orphan drug development. Strategic applications of biomarkers and surrogate endpoints for the development and approval of a product used to treat an orphan disease will be highlighted with examples of approved products. Continued efforts are still needed to fill in our knowledge gap and to strategically link biomarkers and surrogate endpoints to clinical responses for rare diseases and diseases affecting neonates and infants.
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Affiliation(s)
- Jane P F Bai
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, FDA, Silver Spring, MD, USA.
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White paper: recommendations on the conduct of superiority and organism-specific clinical trials of antibacterial agents for the treatment of infections caused by drug-resistant bacterial pathogens. Clin Infect Dis 2012; 55:1031-46. [PMID: 22891041 PMCID: PMC3657525 DOI: 10.1093/cid/cis688] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 08/03/2012] [Indexed: 11/13/2022] Open
Abstract
There is a critical need for new pathways to develop antibacterial agents to treat life-threatening infections caused by highly resistant bacteria. Traditionally, antibacterial agents have been studied in noninferiority clinical trials that focus on one site of infection (eg, pneumonia, intra-abdominal infection). Conduct of superiority trials for infections caused by highly antibiotic-resistant bacteria represents a new, and as yet, untested paradigm for antibacterial drug development. We sought to define feasible trial designs of antibacterial agents that could enable conduct of superiority and organism-specific clinical trials. These recommendations are the results of several years of active dialogue among the white paper's drafters as well as external collaborators and regulatory officials. Our goal is to facilitate conduct of new types of antibacterial clinical trials to enable development and ultimately approval of critically needed new antibacterial agents.
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